Fallon Health Director, Provider Contract Management in Network Development - Health Insurance - Hybrid Remote!! in Worcester, Massachusetts
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Brief summary of purpose:
The Director of Contract Management position will execute on contract strategies and manage the activities of the Contract Management function inside NDM and its staff. The Director works closely with other internal Fallon departments to communicate identified problems and issues that arise within the contracting framework of provider networks. Must have a solid understanding of provider fee schedules, reimbursement methodologies (facility, professional, value-based and otherwise), provider contract strategies as well as industry standards for provider payment policies. The Director will collaborate with the Directors of Provider Relations, NDM Ancillary and Vendor Relations as well as the Director of NDM Operations and with the VP of NDM to develop and implement all Corporate and Department strategies.
Adding this position back to the NDM organizational structure will strengthen the focus of the NDM contracting team on consistent pricing, timely renewals, oversight of reimbursement trends and membership growth tied to our provider partners. This position will support and drive the contracting strategies developed by the VP of NDM.
Thorough knowledge of government regulations as dictated by regulatory agencies (NCQA, HCFA, etc.)
Requires a high level of analytical ability, initiative and judgement.
Demonstrated negotiation skills and the ability to formulate coherent strategies in a rapidly changing provider environment. A high level of diplomacy is necessary to anticipate, recognize and deal effectively with politically sensitive issues.
Requires sensitivity regarding network issue sand the political instincts to deal effectively with conflicting interests.
Requires the ability to understand the nuances of the Health Plan’s numerous product lines and the unique operational and financial features associated with each of these products.
Frequent contact with physicians, administrators and hospital senior management necessitates excellent interpersonal and communication skills.
Requires a strong personal presence that will engender confidence among providers
Strong sales persuasion skills as well as the ability to communicate complex qualitative information in a variety of provider settings.
Must be able to work cooperatively as a team member and promote the development of strong work relationships with various departments throughout the company.
Essential functions occur simultaneously, therefore the Director must be able to appropriately handle each essential function, prioritize them and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment.
Ability to learn and apply Fallon policies consistently and seek out guidance when necessary.
Bachelors Degree required. masters Degree in buisness or Public Health preferred.
Valid Driver’s License and Clean Driving Record Required
At least 7 years of progressive and responsible experience in healthcare management with a thorough understanding of the healthcare market and the needs/concerns of healthcare providers. Must have a proven ability to achieve goals and to deliver bottom line results. Requires excellent working knowledge of managed care contracting including the fundamentals of contract design, variations in provider compensation arrangements including capitation, and a working knowledge of hospital reimbursement. Requires experience with advanced financial and analytic models. Must have a demonstrated ability to communicate effectively with physician leaders and high-level hospital administrators. Requires excellent negotiation skills.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Posted Date 3 months ago (7/29/2021 3:20 PM)
Job ID 6217
# Positions 1
Category Network Development