Mgr, Network & Physician Contracting

About the role

Lead/support the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum.

Work with the Director on the fee-for-service (FFS) and value-based payment contracting initiatives, collaborating with payment evolution team to introduce the appropriate updated payment models (whether FFS or value based) and provider experience team to meet provider expectations.

Lead/support complex negotiations and/or contracting arrangements which require developing a sound business strategy for the financial and legal terms required for contracting initiatives.

Manage all the regulatory, accreditation and enterprise network adequacy requirements to ensure Horizon’s 3.5 million members have access to a broad network across all its lines of business.

Perform quarterly analyses of the provider network from a cost, coverage and growth perspective.

Lead the evaluation of opportunities to expand or modify the network to meet the Enterprise goals.

Manage budgeting and forecasting initiatives for product lines to network costs and provider contracts.

Contribute to drafting hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and enterprise requirements while advancing Horizon’s strategic and business objectives.

Responsibilities

• Manage the development and execution of the network contracting strategy, including methods to adopt value-based contracting for providers operating under fee-for-service models, minimize special arrangements, and align to enterprise affordability objectives.
• Manage and negotiate contracts in compliance with Horizon reimbursement standards, and other key controls.
• Aid and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
• Ensure accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider file maintenance requests, claims stops and new hospital implementation.
• Adjudicate technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies.
• Conduct research, identify root cause analysis and work fall out reports causing operational deficiencies.
• Manage the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the core systems.
• Collaborate with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and enterprise requirements.
• Understand the Enterprise Strategic and Financial Plan.
• Understand Value Based Programs including the financial, quality and operational aspects.
• Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business.
• Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, DRG updates and contract storage.
• Manage the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
• Understand the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.
• Implement multi-million dollar medical cost savings by introducing innovative industry initiatives and programs.
• Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
• Collaborate across departments to ensure that provider services are aligned with the needs of members and the organization.
• Assist with keeping the provider network integrated with the organization’s objectives.
• Provide management level leadership and support all of the contracting staff.
• Develop and train staff; develop and monitor goals; conduct annual performance reviews, and administer salaries for the staff.

Requirements

This manager should have a demonstrated track record of creating and developing and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers.

This manager will lead a team of specialists, and independent contributors.

Excellent communication and leadership skills are needed as this manager will work with a range of stakeholders both internally and externally.

This position will manage negotiations and contracting with all providers for all payment arrangements, including value-based primary and specialty programs.

This team will also negotiate, execute, renew contracts for all providers and all payment arrangements.

They will maintain contract standards and policies.

They must collaborate with payment strategy team on contracting parameters and provider experience team on relationships.

Finally, they must recruit and contract out-of-network providers.

Qualifications

• High School Diploma/GED required.
• Bachelor degree preferred or relevant experience in lieu of degree in health or health care related field from an accredited college or university or relevant experience.
• Minimum of 5 years demonstrated business experience in hospital and provider group finance and/or managed care network development.
• Minimum of 5 years in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Medicare DRG and APC’s, Medicaid pricing, capitation, full risk, shared savings and incentive arrangements.
• Minimum of 5 years’ experience in successfully leading cross-functional teams to achieve improvements.
• Minimum of 5 years prior provider experience in Commercial, Medicare, Medicaid, and Value Based Programs is required.
• Minimum of 3 years’ experience in health care cost data analysis and technical document writing.
• Minimum of 3 years supervisory experience and/or leading people by influence.

Skills

• Demonstrates ability to create, develop, and maintain business relationships.
• Proven analytical, business case and product design skills a must.
• Proven ability to exercise sound judgment.
• Proven ability to ask probing questions and obtain thorough and relevant information.
• Strong organizational skills.
• Effective verbal and written communication skills.
• Proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint).
• Knowledgeable in the use of intranet and internet applications.
• Knowledgeable in the hospital and physician communities in the state of New Jersey.
• Knowledgeable in laws and regulations regulating insurance, HMO hospital and physician practice.
• Knowledgeable in quality measurement approaches applied in measuring insurance, HMO, hospital, and physician practice.