Fallon Health Senior Director, Provider Contracting & Network Strategy - Growing Government Health Programs! in Worcester, Massachusetts
Fallon Health is a company that cares. We prioritize our members—always—making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation’s top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs—including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)— in the region.
The Sr. Director of Provider Contracting and Network Strategy Leads a team of 9 contract directors, managers and contracting specialists from initial contract strategy through contract negotiation and agreement implementation. Adding this position back to the NDM organizational structure will strengthen the focus of the NDM Hospital and Physician contracting team on consistent pricing, financial models, timely renewals, oversight of reimbursement trends and membership growth tied to our provider partners. This position will also provide strategic leadership into the eastern Massachusetts provider community and help expand Fallon’s risk and value-based relationships throughout the network.
The Sr. Director of Provider Contracting and Network Strategy position will develop and implement contract strategies and manage the activities of the Contract Management function inside NDM across multiple product lines: Medicare Advantage, SCO, PACE and Medicaid ACO
Lead a team of 9 contract Directors, Managers and Contracting Specialists from initial contract strategy through contract negotiation and agreement implementation
Provide strategic direction and guidance on all provider negotiations, taking primary responsibility for complex and strategic negotiations, as applicable
Design, as necessary, and utilize financial analysis and medical informatics to determine appropriate reimbursement rates and methods
Negotiate financial models, rates and contract terms, including performance-based reimbursement models, to meet strategic goals
Work with Actuarial and Medical Economics teams to establish and monitor provider contract budgets
Work closely with other internal Fallon departments to communicate identified problems and issues that arise within the contracting framework of provider networks.
As an organization leader and subject matter expert, provide thoughtful and engaged leadership both within direct area of responsibility, across the organization and with external entities
At least 10 years of progressive and responsible experience in healthcare management with a thorough understanding of the healthcare market and the needs/concerns of healthcare providers.
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.
A high level of analytical ability, initiative and judgement
Experience with advanced financial and analytic models, hospital and physician reimbursement methodologies, including value based and capitated programs, provider contract strategies as well as industry standards for provider payment policies
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
Sensitivity regarding network issues and the political instincts to deal effectively with conflicting interests
A strong personal presence that will engender confidence among providers
Strong sales persuasion skills as well as the ability to communicate complex qualitative information with physician leaders and high-level hospital administrators.
Bachelors degree required. Masters degree in Business or Public Health preferred but not required.
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.
Fallon Health Vaccination Requirements:
To protect the health and safety of our workforce, members and communities we serve, Fallon Health now requires all employees to disclose COVID-19 vaccination status. As of 2/1/2022 all roles not designated as “Remote” require full COVID-19 vaccination and Fallon Health will obtain the necessary information from candidates prior to employment to ensure compliance. Failure to meet the vaccination requirement may result in rescission of an employment offer or termination of employment.
Posted Date 5 months ago (4/25/2023 2:28 PM)
Job ID 7283
# Positions 1
Category Network Development