Sr. Manager of Provider Contracting

Purpose

Leads and oversees Network Strategy and Management /Provider Contracting teams ensuring business strategies, plans and initiatives are executed / delivered in compliance with governing regulations, internal policies and procedures. The Sr. Manager of Provider Contracting is responsible for developing, maintaining, and ensuring adherence to internal controls as well as compliance with applicable laws and regulations which follow Health New England's entity level policies and procedures.

The Sr. Manager of Provider Contracting is responsible for leading and assisting the Provider Contracting team with provider network and provider-vendor network development activities for commercial and government programs including: preparing contract proposals in accordance with financial, operational and quality objectives, drafting and negotiating contract terms, overseeing contract implementation and developing contract maintenance processes and protocols.

The position is also responsible for reporting unethical or fraudulent activity related to business operations and adhering to Health New England's Code of Conduct.

Accountabilities

• Leads and drives a customer focused culture throughout their team to deepen client relationships and leverage broader business relationships, systems and knowledge.
• Understand how Health New England's business and culture should be considered in day-to-day activities and decisions.
• Creates an environment in which the team pursues effective and efficient operations of their respective areas in accordance with Health New England's Values, its Code of Conduct and the Associate Handbook, while ensuring the adequacy, adherence to and effectiveness of day-to-day business controls to meet obligations with respect to operational, compliance, and conduct.
• Builds a high performance environment and implements a people strategy that attracts, retains, develops and motivates their team by fostering an inclusive work environment and using a coaching mindset and behaviors; communicating vison/values/business strategy; and, managing succession and development planning for the team.
• In collaboration with the Sr. Director and VP of Network Management & Corporate Strategy, develops and directs the overall HNE network strategy for both contracted providers and outsourced network vendors (provider-vendor) for risk and non-risk contracting by: identifying network gaps, assessing network expansion opportunities, financial modeling (incorporating utilization and trend data), developing rate and risk share proposals, and drafting proposed custom contract language.
• Establishes and maintains positive relationships and acts as key escalation point for contract issues with providers and provider-vendor as well as their senior leadership
• Facilitates the identification and resolution of ongoing operational issues with providers and provider-vendors, including but not limited to: billing/claims, configuration/system implementation, reporting/analytic needs, and non-compliance by coordinating with the Provider Relations department as well as other functional units within HNE.
• Develops and maintains provider-vendor service level agreements (SLAs) incorporating both network adequacy and traditional vendor performance metrics to holistically mange the network and agreements.
• Designs and reviews SLA reporting to monitor trends and identify areas of opportunity to either expand or restrict out-sourced relationships.
• Adopts and promotes a culture of continuous process improvement leveraging best-in-class practices as well as technological solutions.

Job Title: Sr. Manager of Provider Contracting/ Provider Contracting

Reporting Relationships (Job Titles only)

Manager:

(include secondary Manager if applicable)

Sr. Director of Network Strategy & Management

Direct Reports:

Provider Contracting Manager

Provider Contracting Specialist

Sr. Provider Contracting Specialist

Shared Reports (solid/dotted if applicable):

N/A

External/Internal Contacts

Internal

Credentialing & Provider Enrollment

Provider Relations

Finance

Healthcare Services

Executive Leadership Team

Legal

External

Hospitals, PHO's, and IDN's

Assigned Venders

Department of Insurance

Department of Health

Healthcare Trade Organizations

Education / Experience / Other Information (include only those that are specific to the role)

Bachelor's degree required, Master's Degree Preferred (relevant experience considered in lieu of degree)

• Industry experience -
  • 7-10 years of experience in the health care industry (at least 3 years in managed care contracting)

Strong knowledge of commercial and government programs reimbursement methodologies and risk sharing models

Ability to use financial and utilization data to formulate rate proposals within budgeted financial targets and evaluate financial impact of changes in payment terms

• Product knowledge -
  • In-depth understanding of healthcare product and financing offerings
• Specific regulatory or compliance knowledge
  • General understanding of all healthcare related regulations