Senior Director, Contract/Network Management

Description : Job Summary :

Under the direction of the Vice President of Contracting Strategy and in close collaboration with TSPMG and KFHP senior leadership, leads the development of contracting strategy and identification of network needs within the Georgia service areas.

Conducts a coordinated approach to managing and enhancing relationships with contracted providers and institutions. Critically oversees contracted cost / unit to ensure competitive and appropriate outside medical costs.

Essential Responsibilities :

• Oversees institutional and provider contracting to ensure outside medical costs are competitive and appropriate for our market.
• Ensures accurate performance of all contracts and capitated agreements; routinely monitors performance, reports to medical group leadership routinely, and takes corrective action as necessary.
• Manages non-Permanente physicians and hospitals commensurate with contract terms; provides utilization feedback to physicians to better manage their costs and reduce variation.
• From a contracting perspective, performs lead role in coordinating and executing Network Smoothing to ensure communication and contract terminations are timely and compliant with regulatory requirements.

Designs strategies to minimize negative reactions and damage to KP brand.

• Responsible for contracting cycle for network providers : network strategy, contracting, cost analytics, contract load in claim system and management of providers.
• Assures departments comply with federal and state regulations, NCQA, CMS, SOX, internal compliance, and internal audits from program office.
• Designs dynamic communication tools to describe our contracted delivery system including timely notification of changes and updates.
• Accountable for provider demographics, contract build in claim system and provisioning of network providers for access to Healthconnect.
• Develops and implements Contracting and Network Management goals and initiatives in support of regional business plan and strategies.
• Executive responsibility for effectiveness of contract negotiations with medical providers including medical groups, hospitals and all ancillary providers to include being the lead negotiator on complex or high level contract discussions.
• Responsible for the financial analysis of contracts in a timely and ongoing manner to ensure proactive renegotiation as needed.

Responsible for the preparedness of potential upcoming negotiations of existing contracts.

Assures use of standard Kaiser Permanente contract forms, implements contracting process improvements and works with Health Plan legal counsel to develop all contract modifications.

Safeguards the interests of TSPMG and Health Plan while allowing the maximum legal protections and flexibility for the organization.

• Establishes and maintains favorable relationships with hospital systems and network physicians contracted with TSPMG and KFHP of Georgia.
• Gathers and maintains competitive information including competitors network composition, network reimbursement, provider incentive arrangements, medical and utilization management practices, and technology and electronic communication methods used by competitors in support of their network providers.

Reports to medical group leadership quarterly or more often if appropriate.

Understands the reimbursement capabilities of the KFHP Georgia claims administration department and creates cost-saving provider reimbursement strategies and practices consistent with these capabilities;

identifies areas where our claim system should be enhanced to support more sophisticated contracting strategies.

• Collaborates effectively with claims, quality and utilization management department and benefit administration to ensure that contracts are administrable.
• Assists in development and administration of performance incentive programs for contracted external providers and manages the communication of physician profiling results to non-TSPMG physicians.
• Serves as the Georgia liaison to National Provider Contracting and oversees implementation of best practices to improve organizational effectiveness.
• Responsible for national contract management system by serving on national change control boards, system development, and on-going support of the system.
• Assures accurate execution and implementation of financial and operational contract terms, conditions and obligations for the Health Plan, TSPMG and the contracted providers.

Develops and applies tools and guidelines to improve financial, claims administration and compliance performance of contracted providers.

• Facilitates and sponsors cross-functional workgroups and task forces to plan the deployment of new business strategies among contracted physicians and the introduction of new products in a timely manner.
• Works with marketing for network needs to include responding to RFPs, network composition and product development.
• Analyzes reviews and offers options for unique specialty care needs, new technology, cost implications of internalization of medical services, increasing costs associated with non-contracted or under-contracted services, unsatisfactory results with existing contracts, demographic changes to membership and associated health care issues, and the political climate in the provider community.
• Develops and implements adequate provider educational activities for contracted providers to assure provider satisfaction and dispute resolution.

Develops and maintains provider manuals and educational materials.

Works closely with the Network Medical Director, other TSPMG physician leaders, local physicians, and staff in developing operational processes for contracted physicians to implement clinical / medical policies, including practice and referrals guidelines, peer review parameters, utilization review policies, and quality assurance activities.

Ensures communication of medical management procedures, compensation models, and profiling information to network providers as appropriate.

• Consistently supports compliance and the Principles of Responsibility (Kaiser Permanentes Code of Conduct) by maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting non-compliance, and adhering to applicable federal, state and local laws and regulations, accreditation and licenser requirements (if applicable), and Kaiser Permanentes policies and procedures.
• Your access to protected health information (PHI) will be limited to the minimum necessary required to effectively perform your job.
• May perform other duties as assigned.

Basic Qualifications :

Experience

Minimum fifteen (15) years of progressive responsibility in health care with at least ten (10) years of direct provider contact in network development, contracting and / or provider relations.

Education

Bachelors degree in health care administration, business administration, or related field required.

License, Certification, Registration

N / A

Additional Requirements :

• Ability to perform financial analysis and managed costs.
• Ability to analyze complex problems and problem-solve using a team approach.
• Strong orientation toward superior provider and customer satisfaction.
• Effective interpersonal and conflict resolution skills.
• Experience negotiating complex, large financial volume agreements with hospitals, physicians, and ancillary services.
• Experience in utilizing contract management system.
• Experience developing and administering capitated agreements.
• Project management, department management or supervisory experience.

Preferred Qualifications :

• Experience developing and administering provider incentive and pay-for-performance programs preferred.
• Perspective Skilled - Looks toward the broadest possible view of an issue / challenge; have broad-ranging personal and business interests and pursuits;

can easily pose future scenarios; can think globally; can discuss multiple aspects and impacts of issues and project them into the future preferred.

• Developing Direct Reports - Provides challenging and stretching tasks and assignments; holds frequent development discussions;
• is aware of each direct reports career goals; constructs compelling development plans and executes them; pushes direct reports to accept developmental moves;

will take direct reports who need work; is a people builder preferred.

Interpersonal Savvy - Relates well to all kinds of people, up, down, and sideways, inside and outside the organization;

builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact; can diffuse even high-tension situations comfortably preferred.

Composure - Is cool under pressure; does not become defensive or irritated when times are tough; is considered mature; can be counted on to hold things together during tough times;

can handle stress; is not knocked off balance by the unexpected; doesnt show frustration when resisted or blocked; is a settling influence in a crisis preferred.

• Building Effective Teams - Blends people into teams when needed; creates strong morale and spirit in his / her team; shares wins and successes;
• fosters open dialogue; lets people finish and be responsible for their work; defines success in terms of the whole team;

creates a feeling of belonging in the team preferred.

Delegation - Clearly and comfortably delegates both routine and important tasks and decisions; broadly shares both responsibility and accountability;

tends to trust people to perform; lets direct reports finish their own work preferred.

• Negotiating - Can negotiate skillfully in tough situations with both internal and external groups; can settle differences with minimum noise;
• can win concessions without damaging relationships; can be both direct and forceful as well as diplomatic; gains trust quickly of other parties to the negotiations;

has a good sense of timing preferred.

Political Savvy - Can maneuver through complex political situations effectively and quietly; is sensitive to how people and organizations function;

anticipates potential barriers and sensitivities and plans his / her approach accordingly; views corporate politics as a necessary part of organizational life and works to adjust to that reality preferred.