We enjoy the important work we do every day on behalf of our members.
Job Summary
Reporting to the President of Medicare, the leader is responsible for developing and maintaining high performing provider networks to meet membership, earnings, medical loss ratio, and quality goals for Medicare Advantage plans across multiple states. The leader is responsible for monitoring and analyzing trends in medical cost and working with cross functional team to direct actions to improve network, provider and product performance. The leader is also responsible for developing and maintaining strategic provider relationships that enable success for the plan and risk sharing provider organizations.
The Leader will have two or more directors, a team of contract and provider group performance managers, analysts and program managers. The role will work closely with the Medicare medical director, actuarial, health care services, sales, and risk adjustment leaders and externally with leadership of large integrated delivery networks and other strategic providers.
Job Description
Provider Network Strategy and Development
Lead the development of Medicare Advantage network and contract strategies to meet goals for membership, quality of care, medical cost and earnings. Build and maintain high performing provider networks utilizing risk-based structures and incentives whenever possible. Identify and recommend changes to networks as needed
Provide direction, strategy and parameters for risk sharing contract structures, payment models, and performance incentive programs to support achievement of cost and quality goals.
Monitor and assess trends and changes in the provider landscape, and in federal and state payment policies and methodologies to identify potential opportunities and threats. Proactively recommend actions to address
Stay abreast of industry trends and best practices and utilize this knowledge to refine and advance network and payment strategies, models, and structures
Contract Negotiation and Management
Provide oversight and direction to team that that contracts with physicians, ACO, hospitals to meet business goals and regulatory timelines.
Coach and direct staff to devise proposals, strategies and options for contract negotiation. Develop negotiation strategy for largest provider systems. Lead or participate in negotiation with the largest strategic providers
Develop and maintain optimal provider networks. Assess, monitor and manage network adequacy to meet federal and state regulations. Proactively identify and close network gaps
Collaborate with Enterprise Allied Health Contracting to ensure allied health and BH/SA networks and payment terms support Medicare division needs and goals. Assess and monitor allied payment rates and recommend changes to methodology and rates to align incentives and manage expense trends.
Collaborate with colleagues in the Enterprise Network Operations to ensure
Timely and accurate contract implementation, configuration, and accurate ongoing contract administration
Effective provider relations support, including escalated claims resolution, education and communication
Provider and Medical Cost Performance Management
Leverage department and enterprise analytics, reporting and tools to monitor, analyze and assess performance of contracts, incentive structures, individual provider groups, networks and products
Using analytics, collaborate with cross functional leaders to identify opportunities to improve performance of the above. Engage leaders to identify, assess, prioritize and implement interventions to meet targets for
Collaborating with the Health Care Services MCI and pharmacy teams, lead and oversee the division's medical and pharmacy cost trend mitigation efforts to meet cost targets. Utilize data to identify cost and utilization performance opportunities. Identify and champion programs, actions, and strategies that will improve performance. Collaborate to assess, evaluate and develop business cases for implementation
Partnering with the division President, sr. medical director and enterprise function leaders to ensure the development and execution of a medical cost savings agenda that meets the division's annual goals. Lead the process to identify, assess, prioritize and implement initiatives to reduce medical cost trend. Collaborate with leaders across the enterprise to identify initiatives to meet targets. Collaborate with enterprise Medical Cost Innovation team to identify enterprise wide initiatives that can be implemented for Medicare.
Lead a team to monitor and oversee the performance of provider contracts, payment methods, incentives and other key terms. Proactively refine and modify strategies and terms to adapt to changes in business and to improve performance or improve cost, utilization
Oversee a team of analysts and provider group managers who monitor and analyze provider group performance trends and identify improvement opportunities. The team will collaborate with the division medical director, population health, and risk adjustment leaders to develop strategies and implement actions to improve performance. Support provider engagement meetings with cross functional stakeholders and provider group clinical and business leadership, as needed
Collaborate with Actuarial and Enterprise Analytics to ensure proper performance analytics, tools, templates and processes are in place to support effective performance management
Support the division president in planning and executing the quarterly business review (QBR) of the business segment's performance with company leadership
Strategic Relationship Management
Develop and maintain strategic provider relationships that support collaboration and engagement on performance improvement plans and the achievement of business objectives
Collaborate with Commercial and Public Plans on shared strategic provider relationships to coordinate, develop and implement a proactive relationship management approach that supports long-term, mutually successful relationships with strategic providers
Talent Management and Team Building
Recruit, retain and develop talent. Coach and support staff in negotiation, analytics, and relationship management to enable a high-performing team of provider professionals
Requirements
EDUCATION:
Masters degree in business, health care or related field
MBA strongly preferred
EXPERIENCE:
Minimum of 10 years of progressively responsible management experience in a complex healthcare setting
Previous experience with Medicare Advantage and experience working collaboratively with providers highly desired
Experience managing analytics highly desired
SKILL REQUIREMENTS:
Energetic, goal driven leader with a proven ability to deliver bottom line results who can motivate and mobilize staff to achieve goals
A strategic thinker who is able to synthesize information, assess implications and formulate plans for action
Strong working knowledge of managed care/risk contracting payment methodologies
Savvy negotiator with experience in a range of provider payment methodologies including risk. Demonstrated experience in direct, high level negotiations with the proven ability to close a deal
Excellent quantitative and analytic skills with ability to synthesize complex information, create and evaluate options
Excellent interpersonal communications skills and a high level of diplomacy to anticipate, recognize and deal effectively with politically sensitive issues
Strong relationship building skills to influence and work collaboratively with physicians and other provider leaders
Excellent leadership skills to guide, inspire and develop a high performing team of professionals
Working Conditions or Additional Requirements
Must be able to excel in a fast-paced business environment handling multiple priorities. Must be highly effective in both written and oral communication. Must be able to exercise appropriate judgment when making decisions. Must be able to work in excess of 40 hours per work as the job may require, including evenings and weekends. Some local travel required.
Confidential Data
All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Will be exposed to and required to deal with highly confidential and sensitive material. Must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
