The Director Provider Contracting and Network Performance is responsible for the negotiation, management and oversight of all risk contracts with organized provider groups for the southeast and east Michigan regions for all BCBSM lines of business (Blue Care Network, Blue Care Network Advantage, Medicare Advantage PPO and BCBSM PPO (future development).
In collaboration with other teams in the organization, the Director, is responsible for establishing and implementing the network performance improvement strategy for the provider organizations for these two regions;
The Director (together with the West Director) is responsible for the development and management of networks for alternative network products, including provider specific products.
The Director is responsible for negotiating contracts with specialty groups for BCN.
ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.
Negotiate/and direct negotiation of risk contracts with organized provider groups.
Oversee network performance improvement strategy and activities with organized provider groups.
Track overall risk group performance and focus resources to identify and resolve issues related to risk arrangements.
Develop networks and evaluate performance for alternative network products, include narrow network and provider partnered products.
Negotiate specialist contracts for BCN where applicable.
Collaborate with provider financial analysis and actuary on target development and provider risk models.
Participate in the development of overall provider strategies for the BCBSM.
Provider subject matters expertise to other areas within BCBSM (included Health Plan Business, Senior Health Services, Corporate Strategy.
It is the responsibility of the director to identify and implement servicing improvements, facilitate provider education initiatives and direct implementation of new products and programs as they impact the provider community. The director will be responsible for establishing performance improvement programs, including contracting, with designated primary care groups, primary care physicians, specialists and other providers.
Promote the delivery of cost effective and quality care to BCN members, Promote a cooperative and mutually beneficial relationship between BCM and its providers, Increase provider satisfaction with BCN.
Responsible for establishing department goals, monitoring departmental budgets, developing and monitoring team member training education and development.
Interacts with network providers and PCGs regarding reimbursement, provider payment, new products and education.
Responsible for directing all activity associated with the implementation of new products, programs and services.
Corporate work groups and committees.
Other duties as assigned by Vice President.
Bachelor's degree required.
Master's degree in business or health care administration preferred.
Seven years in healthcare industry, with at least three years experience in a management role.
BCN experience preferred.
Experience with leading team required
Experience in developing leadership communication required.
Broad knowledge of healthcare delivery systems, managed care principles and practices, and managed care operations
Knowledge of how to manage people and projects
Familiarity and understanding of provider group models and their operations.
Knowledge of state and federal regulatory requirements, NCQA and HEDIS policies as they pertain to network provider activities and plan performance
Knowledge of BCN and BCBSM areas to support departmental goals preferred
Ability to lead teams and pull together diverse parties to support comprehensive servicing.
Strong analytical skills
Ability to work effectively and build relationships with multiple clients (both internal and external) and to handle multiple projects and implementation timeframes
Ability to work across the enterprise with different areas and different levels of management
Strong organizational skills and follow-through with particular attention to detail
Demonstrated flexibility, self-discipline and ability to work independently.
Excellent writing skills.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.