Primary Purpose of Position:

The Director Provider Network Contracting initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for Partners Health Management for the health products offered. The Director Provider Network Contracting works on problems of diverse scope and complexity ranging from moderate to substantial.

The Director Provider Network Contracting communicates contract terms, payment structures, and reimbursement rates to providers. Analyzes financial impact of contracts and terms. Maintains contracts and documentation within a tracking system. May assist with identifying and recruiting providers based on network composition and needs. Advises leadership to develop functional strategies (often product specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.

This position will provide leadership and oversight of the Provider Network Contracts Unit, subject to legal support/consultation as needed. Work involves data entry and analysis, data mining, data management, reporting, record keeping, and providing, managing and coordinating the provision of a full range of support activities necessary for the effective leadership, recruitment, execution and management of contracting data and activities for the for the department.

Role and Responsibilities:

• This position is responsible for all duties related to managing payor contracts, including to the extent allowed by law, negotiation and renegotiation of new and existing payor contracts
• This position works closely with members of the Provider Enrollment and Maintenance and Office of Legal Affairs (OLA) teams to ensure contracts are appropriately identified, negotiated, implemented, audited and renegotiated in a timely manner
• This position requires prior knowledge of Managed Care in a Provider or Payor setting in addition to understanding of Payer Contracting tasks and activities
• Proficient in the development, coordination and analysis of payor contracts
• Responsible for efficiently and effectively negotiating payment terms and rates for new and existing contracts that are favorable for the organization, subject to supervision by an attorney to the extent required by law
• Proficient in the review of contract terms and conditions in order to facilitate accurate implementation of contracts
• Responsible with legal supervision for the maintenance of contract templates and approvals from NCDHHS to ensure compliance with the Tailored Plan and Medicaid Direct Contract requirements.
• Proficient in monitoring renewals of contacts as assigned and renegotiating contract rates and terms as appropriate upon renewal
• Resolve escalated contract specific issues, including attorney oversight as appropriate
• Supervision and coaching of Contracts staff in complex, time-sensitive regulatory matters.
• Evaluate, understand, and negotiate provider contracts in compliance with company templates, reimbursement structure standards, key process controls and the laws, rules and regulations against the unauthorized practice of law (UPL)
• Influence and/or provide input to forecasting and planning activities for network growth
• Manage performance target setting, performance reporting and associated financial models relative to provider network contracting
• Establish and maintain strong business relationships with assigned providers and internal partners
• Design reports for internal and external recipients, which may require independent research.
• Work with internal departments to compile and analyze contract data and documentation for audit review & quality improvement.
• Produce and examine reports, gather and coordinate submission of State reports as mandated. Respond to requests from other Partners staff, particularly concerning provider status.
• Receive, review, analyze, track and maintain timely records of time sensitive and confidential information.
• Responsible for accurate and timely maintenance of provider information essential to Partners ability to accurately track network provider contracts; process authorizations and claims; and produce an accurate provider directory. It is critical that the staff person in this position be accurate and thorough in the completion of their duties.
• Failure to input accurate and complete information has the potential to negatively impact the service delivery system and consumer ability to access services in a timely manner.
• Participates in on-going quality improvement activities with other departments including UM, Claims, Care Coordination and IT.
• Work with OLA, Finance and other departments to ensure a compliant, consistent companywide contracting and contract management system

Knowledge, Skills and Abilities:

• The Director Provider Network Contracting must have extensive provider contracting skills, including contract preparation and implementation, financial analysis and rate proposal development
• Ability to manage multiple priorities in a fast-paced environment
• Must be passionate about contributing to an organization focused on continuously improving member/recipient experiences
• Strong, working knowledge of data extraction methodologies
• Ability to exercise appropriate judgment and discretion in presenting data
• Excellent written and verbal communication skills
• Experience and ability to present complex data and information to varying audiences, both internal and external, in a professional and clear manner.
• Knowledge of program practices, techniques, and technology sufficient to support the program
• Knowledge of the goals and objectives of the work unit and an understanding of the structure and functions of the organization (must have knowledge of staff assignments/commitments, and the functions of other internal and external organizational segments whose work impacts on the unit or with which work must be interfaced)
• Excellent computer skills; proficient in Microsoft Office Products (Word, Excel, Outlook, Publisher); experience in use of databases
• Ability to practice effective communication techniques, oral and written
• Ability to establish and maintain effective interpersonal and working relationships with internal and external customers
• Ability to analyze and interpret policy and procedural guidelines and to resolve problems and questions, independently
• Ability to complete non-routine activities and tasks that require deviation from established procedures which includes the ability to choose the appropriate course of action and recognize the existence of and differences among situations
• Ability to use initiative and judgment in resolving problems not covered by established priorities or prior experience
• Ability to recognize sensitive or unusual situations that should be internally staffed inclusive but not limited to legal matters for attorney advice
• Ability to manage and uphold integrity and confidentiality of sensitive data
• NC Residency is required

Education and Experience Required:

• Bachelor’s degree
• 8 or more years of progressive network management experience including hospital contracting, client facing responsibilities, issue resolution, contract negotiations and network administration in a healthcare company

o At least three years of experience in a network management-related role handling complex network providers with accountability for business results.

o At least three years of experience with direct provider contracting, including facility, physician, and ancillary providers

• 2 or more years of project leadership experience

Education and Experience Preferred:

• Master’s Degree
• Experience with ACO/Risk Contracting/Clinical Integrated Networks
• Experience with Value Based Contracting

Paralegal background preferred. At least five years of experience with direct provider contracting, including facility, physician, and ancillary. Experience in healthcare, especially public behavioral health, managed Medicaid, and healthcare payor systems and law. No law license is required as any legal work will be under the supervision of an attorney and legal staff.

Licensure/Certification Requirements: N/A