Job Description

SKILLS & COMPETENCIES

• Identifies, evaluates, and executes contracting and network development strategies in established and new markets.
• In conformance with corporate standards and performance targets, negotiates, implements, and works with medical groups, hospitals, integrated delivery systems, specialist physicians, ancillary providers and supplemental providers/vendors.
• Analyzes current and projected network needs from cost/utilization and competitor standpoints for decision making purposes.
• Negotiates and implements all referral arrangements.
• Negotiates all compensation methodologies including but not limited to capitation, per diems, case rates incentives and value-based programs. Develops new reimbursement models in concert with leadership.
• Conducts contract modeling and analysis in coordination with Finance.
• Analyzes, negotiates, and drafts contract rate and language proposals consistent with corporate guidelines for financial and operational performance.
• Oversees administration of the contracts to ensure anticipated results, identify negative performance trends, and implement cost containment and other improvement strategies.
• Works closely with COO, CMO and Market Presidents and other departments to ensure overall success of the market.
• Collaborate with market leadership team and other departments to ensure contracted network support of operating goals, including STARS, HEDIS, RAF, and other initiatives.
• Participates in market review meetings with regional and corporate leaders to review and improve operational and financial results.
• Develops strong relationships with key provider stakeholders.
• Oversees the maintenance of all contract templates to ensure contract compliance with regulatory requirements and established policies and procedures.
• Oversees any required contract amendments and resolves contract issues.
• Oversees assigned staff; recruits, develops and manages performance.
• Recommends and establishes department metrics. Sets goals for staff and the market.
• Contributes expertise to development of organizational best practices.
• Performs other position duties as assigned.

QUALIFICATIONS

Educational/Experience Requirements:

• 10 years of experience in managed care or health care field, including a strong understanding of reimbursement methodologies, contract language, negotiation strategies, financial modeling and analysis, managed care and Medicare Advantage plans; or any combination of education and experience, which would provide an equivalent background.
• 10+ years of network development experience

Required Skills and Abilities:

• Experience solving problems and dealing with a variety of concrete variances in situations where limited standardization exists
• Experience and ability to communicating to diverse audiences utilizing excellent written and presentation skills
• Experience creatively exercising initiative, logic and sound judgment in the development of strategies and contractual relationships
• Experience organizing and prioritizing
• Experience utilizing solid analytical and/or statistical skills
• Ability and willingness to travel as determined by business need
• Effective verbal and written communication skills, including presentation and training capabilities
• Knowledge of healthcare delivery in non-hospital settings or a closely related field (home health, critical care, hospice, etc.) is helpful but not required.
• Strong knowledge of Medicare managed care
• Network relationship knowledge and skills
• Excellent knowledge of hospitals, managed care finance and contract language
• Excellent interpersonal and relationship management skills
• Proven ability to foster collaboration, value others perspective and gain support and buy-in for organization proposal
• Excellent Microsoft Office skills, including Word and Excel
• Experience with delegated and non-delegated providers

 Supervisory Responsibility: No supervisory responsibilities.

Travel requirements:Travel may be required up to 10% locally or nationally

Work Conditions: Ability to lift up to 20lbs.  Moving lifting or transferring of patients may involve lifting of up to 50lbs as well as assist with weights of more than 100lbs. 

• Ability to stand for extended periods
• Ability to drive to patient locations (ie. home, hospital, SNF, etc)
• Fine motor skills
• Visual acuity

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification.  Management reserves the right to add, modify, change or rescind the work assignments of this position.  Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of this role. 

WELLBE INTRODUCTION

The WellBe care model is a Physician Led, Advanced Practice clinician driven, geriatric care model focused on the care of the frail, poly-chronic, elderly Medicare Advantage patients.  This population is typically underserved and very challenged with access to care.   To address these problems, we have elected to bring the care to the patient, instead of trying to bring the patient to the care. Care is provided throughout the entire continuum of care – from chronic care and urgent care in the home, to hospital, to skilled nursing facility, to assisted living, to palliative care, to end of life care.  WellBe's physician/advanced practicing clinician led geriatric care teams’ partner with the patient’s primary care physician to provide concierge level geriatric medical care and social support in the home as well as delivering and coordinating across the entire care continuum.

GENERAL SUMMARY

The Director Network Management is responsible for meeting the contracting and network management needs for WellBe nationwide.  Since WellBe uses the MA plans network for its referrals, the goal of the Director of Network Management is to develop a “sub-network” of preferred providers within the MA plans’ broad network.  The preferred arrangements do not necessarily involve securing better unit cost discounts, but rather focus on preferential terms that incent improving the total cost of care or episode cost of care and/or the quality of care.   Network arrangements can range from simple, non-contractual, referral relationships, preferred workflows and information exchange between WellBe and the preferred provider, all the way to a value-based arrangement which provides economic incentives to the network provider for better care while they continue to bill the MA plan on a fee for service basis.  WellBe is not currently delegated for claims payment or utilization management services by WellBe payor partners.

The national Director of Network management will work closely with the national and market leadership teams, to identify a preferred list of providers in each market or a single national provider for all markets and then contract with the provider, as needed, and work with operations and IT on implementation and the appropriate work flows and data exchanges.   In short, this position will execute and oversee the performance of informal arrangements or contracts with, specialist physicians, , hospitals, and ancillary service providers (laboratory, radiology, DME, etc), and resolve operational issues that may arise.