Sr. Director, Network Development, Health Plans

Richmond VA 23233

Job Description

The Sr. Director, Network Development, Health Plans leads the market’s strategy and planning in the successful development of the provider network, including development, contracting and management of provider relationships and communications for Magellan Complete Care (MCC) of Virginia. This position provides leadership, guidance and oversight to a team of directors, negotiators and consultants to ensure network competitiveness, service and profitability, ensuring the network is of highest quality, cost efficient and provides access to our members. The Director develops the network, assuring network adequacy and access to member choice in compliance with federal and state laws and negotiates and services larger and more complex market/national/group-based providers in accordance with company standards in order to maintain and enhance provider networks while meeting and exceeding accessibility, quality and financial goals and affordability initiatives. Responsibilities and complexities may vary by market and may be organized by services, such as hospitals, providers; or type of contract, such as fee for service or value-based contracting.

Essential Functions

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  • Leads the market’s strategy and planning in the successful development of the provider network including development, contracting and management of provider relationships and communications.
  • Plans, develops and implements a geographically competitive, broad access network that meets objectives for unit cost performance and trend management.
  • Implements actions to build out network expansion markets and/or to close gaps.
  • Meets with key providers to ensure service levels are meeting or exceeding expectations.
  • Evaluates, negotiates and supports larger and more complex market/national/group-based providers in compliance with company standards while meeting and exceeding accessibility, quality, financial goals and cost initiatives.
  • Leads and manages a high performing team who develop, negotiate, contract and enhance collaborative provider relationships, ensuring overall network competitiveness and profitability within market.
  • Advances company’s strategy to adopt value-based payment models; may directly lead teams to develop, negotiate, implement and manage complex value-based arrangements.
  • Oversees and/or negotiates the most complex, competitive contractual relationships with providers according to prescribed guidelines.
  • Provides a solid understanding and expertise in end-to-end aspects of provider contracting from modeling, configuration, utilization management, claims, analytics, including provider risk sharing.
  • Negotiates complex contract language and initiates legal reviews as needed; ensures all required reviews completed by appropriate functional areas.
  • Develops and implements a network strategy to assure long term mutually successful physician, practitioner/facility, and organization provider relationships.
  • Directs all provider (physician, practitioner, facility and organizations) recruitment activities.
  •  Responsible for understanding medical cost issues and medical cost ratios (MLRs) and initiating appropriate action to manage improvement initiatives.
  • Reviews analytics with medical economics and works with providers to develop collaborative initiatives that improve quality results and manage costs.
  • Recruits and ensures provider network includes an appropriate mix of provider specialties to meet the needs and growth of membership.
  • Collaborates with operations to monitor and ensure service issues are resolved, including escalated claims payments/disputes, provider demographics, provider contracting accuracy and credentialing.

General Job Information

Title

Sr. Director, Network Development, Health Plans

Grade

31

Job Family

Operations Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

12/16/2019

Date Requisition Created

12/4/2019

Work Experience

Managed Healthcare, Management/Leadership, Network

Education

Bachelors (Required), Masters: Business Administration

License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements

Responsibilities

Required Qualifications

  • Bachelor’s degree
  • 10+ years of network relations and development, including experience building and maintaining relationships with provider systems.
  • 10+ years of experience in a network management/leadership role, including a successful record of negotiating contracts with individual or complex provider systems of groups and accountability for business results.
  • In-depth knowledge of various reimbursement structures and payment methodologies for both hospitals and providers
  • Knowledge and experience with value-based contracting
  • In-depth knowledge of managed care business, regulatory /legal requirements, products, programs, strategy and objectives.
  • Strong experience building and maintaining relationships with large hospitals/provider systems, integrated delivery system and large physician groups
  • Comprehensive understanding of hospital and physician financial issues and how to leverage technology to achieve quality and cost improvements for both payers and providers.
  • Must live in primary state/market and be able to travel up to 50% within market to visit high-profile provider groups/networks.

Preferred Qualifications

  • MBA/Masters
  • Knowledge of Provider Networks in Virginia is strongly preferred

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.