Director Provider Contracting

JOB SUMMARY

This job is responsible for directing negotiation of the plan’s key contracts with health care providers (hospitals, PHOs, physicians, intermediate care providers).  Directs financial analyses of the provider’s payment history, develops approaches to manage the payout consistent with company parameters, oversees the actual negotiation process, and assumes the lead where necessary.  Responsible for the development, implementation, maintenance, and updating of the plan’s multiple fee schedules and payment methodologies used to reimburse institutional and professional providers.   Implements network contract and reimbursement initiatives as indicated by enterprise and market strategy.

ESSENTIAL RESPONSIBILITIES

• Direct and oversee hospital and institutional provider contract negotiations, taking the lead in complex or high-dollar situations, where appropriate.
• Negotiate rates for nonparticipating provider services or non-contracted services for applicable products.
• Coordinate financial analyses and development of strategies for contract negotiations.
• Manage the design and implementation of provider strategies and reimbursement methodologies aimed at controlling health care costs and evaluate the impact on providers.
• Develop strategic relationships with key provider constituents and maintain critical communication with institutional and professional providers in sensitive contract discussions or in resolving reimbursement issues.
• Generally coordinates and has primary responsibility for all provider reimbursement activities within the Plan, including the execution of initiatives in support of enterprise and market strategy.
• Engage with external consultants as needed to develop and evaluate recommendations related to reimbursement and contract compliance or other reimbursement-related issues.
• May prepare expansion requests for regulatory agencies, oversee the production of provider directories for members, providers, and community agencies, has responsibility for the provider application process and oversee production of and reviews Access & Availability studies and GeoAccess maps, Alternative Language Studies and Encounter Studies for all states and all lines of business.
• Facilitate and oversee CACTUS credentialing database functionality and paperless workflow processes through OnBase document management system.
• Other duties as assigned or requested.

EDUCATION
Required

• Bachelors’ degree in business, finance, information management, healthcare administration or health related discipline or relevant experience and/or education as determined by the company in lieu of bachelor's degree

Preferred

• Master’s degree in Business or Health Care Administration

EXPERIENCE

Required

• 5 years of experience in health care administration/delivery/finance or a related field
• 3 years of experience in a management role

Preferred

• None

LICENSES or CERTIFICATIONS

Required

• None

Preferred

• CPA

Skills 

• Preferred working knowledge of third-party payment concepts, and a solid understanding of health care finance and regional market environment
• Demonstrated ability to act as a spokesman and interface with external corporate officers and consultants in contract negotiations
• Superior ability to analyze data and reimbursement methods to determine strategies and issue resolution in negotiations and other business matters

SCOPE OF RESPONSIBILITY  

Does this role supervise/manage other employees?  

Yes 

WORK ENVIRONMENT

Is Travel Required?

Yes

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This position adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.

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