Director, Provider Contracting - Medicare & Hospital

WORK LOCATION: TEXAS market - can live in Houston, San Antonio, Dallas or Plano

The Director, Provider Contracting - Medicare serves as an integral member of the Network Development and Strategy Team and reports to the Provider Contracting Senior Manager. This role is a key contributor to the development of the strategic direction and is accountable for the management of the fee for service and value based contracting and network management activities for multiple local geographies.

DUTIES AND RESPONSIBILITIES

• Manages hospital system contracting and negotiations for fee for service and sophisticated value-based reimbursements with providers for Cigna’s Medicare product lines (e.g., Hospital systems, Ancillaries, and large physician groups)

• Point person for complex projects related to contracting strategy in the market.

• Proactively builds relationships that nurture provider partnerships and seeks broader value-based business opportunities to support the local market strategy.

• Initiates and maintains effective channels of communication with matrix partners including but not limited to, Claims Operations, Medical Management. Credentialing, Legal, Medical Economics, Compliance, Sales and Marketing and Service.

• Manages strategic positioning for provider contracting, develops networks and identifies and acts on opportunities for greater value-orientation and risk arrangements.

• Contributes to the development of alternative network initiatives. Supports and provides direction to develop network analytics required for the network solution.

• Works to meet unit cost targets, while preserving an adequate and marketable network, to achieve and maintain Cigna's competitive position.

• Creates and manages initiatives that improve total medical cost and quality.

• Drives change with external provider partners by assessing clinical informatics and offering consultative expertise to assist with total medical cost initiatives.

• Prepares, analyzes, reviews, and projects financial impact of larger or complex provider contracts and alternate contract terms.

• Creates Provider agreements (i.e.: Hospital systems, Ancillaries, and Physician Groups) that meet internal operational standards and external provider expectations. Ensures the accurate implementation, and administration through matrix partners. 

• Assists in resolving elevated and complex provider service complaints. Research problems and negotiates with internal/external partners/customers to resolve complex and/or escalated issues.

• Manages key provider relationships and is accountable for critical interface with providers and business staff.

• Demonstrates comprehensive knowledge of providers in an assigned geographic area through understanding the interrelationships as well as the competitive landscape.

• Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance.

POSITION REQUIREMENTS

• Should possess a bachelor’s degree; preferably in the areas of Finance, Economics, Healthcare or Business related. MBA or MHA preferred. Significant industry experience will be considered in lieu of a bachelor’s degree.

• 5+ years Medicare experience required.

• 5+ years Contracting and Negotiating experience involving complex delivery systems and organizations required.

• Experience with Value Base Contracting, a plus.

• Experience leading and mentoring others.

• Experience in developing and managing key provider relationships.

• Knowledge of complex reimbursement methodologies, including incentive-based models strongly preferred.

• Demonstrated experience in seeking out, building and nurturing strong external relationships with provider partners.

• Intimate understanding and experience with hospital, managed care, and provider business models.

• Team player with proven ability to develop strong working relationships within a fast-paced, matrix organization.

• The ability to influence both sales and provider audiences through strong written and verbal communication skills. Expe