Provider Contracting and Network Strategist

Overview

Presbyterian is seeking a Provider Contracting and Network Strategist

The Provider Contracting and Network Strategist is accountable for developing and maintaining comprehensive strategic plans for health plan provider contracting, network development, and network adequacy. Develops and maintains effective working relationships and strategic partnerships with provider organizations at the executive level. Monitors and assesses network adequacy and collaborates with key stakeholders to ensure compliance with federal and state regulatory requirements to meet provider access and availability standards. Performs on-going analyses of the provider network from a cost, coverage, and growth perspective and provides leadership in evaluating opportunities to expand or change the network to meet health plan goals

We're determined to take care of those working in healthcare.

Presbyterian is dedicated to improving people's lives - the lives of our patients and the lives of our coworkers. We're locally owned and operated, which encourages supportive leadership that emplowers employees. And we provide the opportunity to gorw from entry-level to the most senior positions.

Why Join Us

• Full Time - Exempt: Yes
• Job is based at Rev Hugh Cooper Admin Center
• Work hours: Weekday Schedule Monday-Friday
• Benefits: We offer a wide range of benefits including medical, wellness program, vision, dental, paid time off, retirement and more for FT employees.

Ideal Candidate: Masters Degree.  15 years of combined experience in managed care, provider contracting, provider network operations and management, and health plan operations experience

Qualifications

• Bachelors degree or equivalent experience in Business Administration, Healthcare Administration or related field. Masters Degree Preferred.
• 15+ years of combined experience in managed care, provider contracting, provider network operations and management, and health plan operations experience.
• Knowledgeable of the full continuum of reimbursement methodologies to include fee-for-service, risk sharing, and capitation Must possess strong communication skills and be comfortable with public speaking.
• Excellent financial and analytics as well as business acumen and familiarity with the operations of sophisticated large integrated delivery systems, innovative business models, managing of a complex multi-institutional and multi-market environment, joint ventures, and evolving population health and payment models.
• Knowledge of current national health care policies and trends, as well as leadership, management, and quality improvement concepts.

Responsibilities

• Serves as a key member of the health plan market expansion and provider network strategic planning team to ensure growth and sustainability.
• Partners with C-level executives to develop sophisticated and compelling value propositions and policy strategies to influence key external stakeholders and decision-makers.
• Develops and negotiates major provider contracting strategies, valued in excess of $1B annually, with large hospital systems and provider organizations.
• Serves as the business owner for complex contract modeling and network adequacy technology, solutions and processes.
• Develops and maintains oversight process of provider contract conformance and performance audits, analysis, and remediation strategies - in partnership with actuarial, finance, medical economics, claims operations, and payment integrity leadership.
• Monitors and assesses network adequacy and collaborates to ensure compliance with federal and state regulatory requirements to meet provider access and availability standards. Identifies areas of opportunity for access needs and partners with relevant stakeholders to enact improvement initiatives.
• Performs on-going analysis of the provider network from a cost, coverage, and growth perspective and is responsible for evaluating strategic opportunities to expand or change the network to meet health plan goals.
• Oversees the development of provider networks across expansion markets by leading provider contract analysis related to due diligence.
• Serves as the subject matter expert for the full continuum of reimbursement methodologies, providing education to mission-critical functions such as provider network, payment integrity, and claims processing.
• Supports budgeting and forecasting initiatives for product lines, in partnership with Finance and product leadership, relating to unit cost increases in medical trend.
• Drives contract efficacy by comparing budgeted medical cost trends against the accumulated annual impact of negotiated rates through collaboration with finance, actuarial, and medical economics.
• Oversees analysis of claim trend data and evaluates market dynamics to inform contract negotiations and ensure strategic focus is on-target with overall health plan strategy.
• Develops and maintains effective working relationships and strategic partnerships with provider organizations at the executive level.
• Collaborates with other Presbyterian System leaders to plan, lead and implement strategies to grow accretive market share and to increase the value of the Presbyterian Health Plan by developing innovative approaches to managing the cost of care.
• Stays current on industry trends, regulatory changes, and emerging models of care delivery to inform and adapt network strategies accordingly.

Benefits

All benefits-eligible Presbyterian employees receive a comprehensive benefits package that includes medical, dental, vision, short-term and long-term disability, group term life insurance and other optional voluntary benefits.

Wellness Presbyterian's Employee Wellness rewards program is designed to provide you with engaging opportunities to enhance your health and activate your well-being. Earn gift cards and more by taking an active role in our personal well-being by participating in wellness activities like wellness challenges, webinar, preventive screening and more.

Why work at Presbyterian? As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans.

About Presbyterian Healthcare Services Presbyterian exists to ensure the patients, members and communities we serve can achieve their best health. We are a locally owned, not-for-profit healthcare system of nine hospitals, a statewide health plan and a growing multi-specialty medical group. Founded in New Mexico in 1908, we are the state's largest private employer with nearly 14,000 employees.

Our health plan serves more than 580,000 members statewide and offers Medicare Advantage, Medicaid (Centennial Care) and Commercial health plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

Maximum Offer for this position is up to

USD $232.50/Hr.

Compensation Disclaimer

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.