Req ID: 65495BR
Provides leadership, guidance and oversight for a team of directors, negotiators and consultants to ensure overall network competitiveness, service and profitability for given market or geographical area. Role may have responsibility for one or more markets, depending on business structure and required complexities. Oversees all network management functions including provider contracting, service, strategic relationships, plan management, and the value based contracting strategy for growth. The role will integrate provider network plans, activities, programs, policies and initiatives in order to effectively manage medical benefit costs while continually improving quality, access and customer satisfaction. Works cross-functionally to establish and execute network strategies.
Fundamental Components included but are not limited to:
(*) Leads and develops the overall network and provider relations strategy for given area of responsibility (i.e. defined geographic area) and drives teams to execution.
(*) Leads the design, development, management, and/or implementation of strategic network configurations that drive membership growth.
(*) Leads and negotiates at the C-Suite level externally and internally in the payer arenas.
(*) Develops, directs and maintains relationships with external and internal care providers and their organizations.
(*) Builds and optimizes community based partnerships.
(*) Provides network strategy support to sales and marketing, along with assistance on community relations related items to achieve market and segment goals.
(*) Oversees and/or negotiates the most complex, competitive contractual relationships with providers according to prescribed guidelines in support of enterprise and local strategies.
(*) Overall accountability for contract negotiations involving all provider types including at-risk arrangements, IPA/PHO, hospital and large provider groups.
(*) Provides a solid understanding and expertise in the end-to-end aspects of provider contracting from modeling, configuration, utilization management, claims and analytics, including provider risk sharing.
(*) Negotiates complex contract language and initiates legal reviews as needed; ensures all required reviews completed by appropriate functional areas.
(*) Supports sales and retention efforts through finalist presentations and engagements with clients, prospects, brokers and consultants.
(*) Ensures network adequacy and implements actions to build out network expansion markets and/or to close gaps.
(*) Advances the company strategy to adopt value based payment models; coordinates with VBC network team and/or may directly lead teams to develop, negotiate and manage complex Value Based and Accountable Care (ACO) relationships.
(*) May oversee the negotiation, implementation and management of VBC agreements.
(*) Manages or leads Joint Operating Committee meetings for VBC arrangements.
(*) Represents the organization at related external provider meetings and conferences.
(*) May have responsibilities related to Joint Venture alliances.
(*) Works closely with Population Health resources to enable and improve clinical outcomes.
(*) Responsible for understanding medical cost issues and medical cost ratios (MLRs) and initiating appropriate action to manage improvement initiatives and scoreable action items.
(*) Reviews analytics with medical economics and works with providers to develop collaborative initiatives that improve quality results, manage costs.
(*) Drives improvement in market provider and member satisfaction results by partnering with medical management, marketing, finance and service operations.
(*) Ensures response to inquiries/issues generated by the provider service center, provider data services and other internal departments to address claims issues, contract interpretation, provider and complex member issues.
(*) Required to communicate with internal and external parties by phone or in person; may require travel to offsite locations.
Qualifications Requirements and Preferences:
(*) 10 or more years experience in managed care; leading and managing teams.
(*) Comprehensive understanding of hospital and physician financial issues and how to leverage technology to achieve quality and cost improvements for both payers and providers.
(*) In depth knowledge of various reimbursement structures and payment methodologies for both hospitals and physicians.
(*) Comprehensive understanding of value based strategies and population health management, and Aetna s related strategic initiatives.
(*) Strong experience building and maintaining relationships with large hospitals/provider systems, integrated delivery systems and large physician groups.
(*) May require knowledge of MACRA and other government programs (ex. Bundled payments) depending on market.
(*) Solid leadership skills including staff development.
(*) Understands the regulatory environment and ensures contractual compliance with federal and state requirements.
(*) Bachelor's degree or equivalent work experience.
(*) MBA/Masters degree preferred.
Network Management - Network market leadership
Desktop Tool - Microsoft Project, Desktop Tool - Microsoft SharePoint, Desktop Tool - Microsoft Word, Desktop Tool - TE Microsoft Excel
General Business - Demonstrating Business and Industry Acumen, Leadership - Developing and Executing Strategy, Service - Demonstrating Service Discipline
General Business - Communicating for Impact, Leadership - Collaborating for Results, Leadership - Driving Change
Additional Job Information:
Job description may also be used for other products besides Commercial medical: e.g., Dental, Worker s Comp, Behavioral Health, Medicare, Medicaid, etc.; systems and tools mentioned in the description would align and reflect appropriate product, segment.
Benefit eligibility may vary by position.
Job Function: Healthcare
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.