What are the responsibilities and job description for the Director, Market Expansion & Contracting (Health Plan) position at Shelby American, Inc.?
Position Overview
The Director, Health Plan Market Expansion & Contracting is responsible for the day-to-day operations of and long-range planning for new market assessments, planning, contracting and related HPMS submissions. In this capacity, the Director will ensure that Verda Healthcare fulfills the triple aim of improving the patient experience and health outcomes in a cost-efficient manner. The Director will also be responsible for the development, implementation and ongoing support of our providers and members incentive program in collaboration with Verda’s Executive Team and business partners.
This Director, Health Plan Market Expansion & Contracting reports to the Senior Vice President of Operations as part of Verda Healthcare, Inc.
Reporting directly to the COO for status, risks, and potential opportunities in the area on a regular basis.
Responsibilities :
- Explore, plan, assess and submit for network market expansion opportunities.
- Plan, implement and manage all contracting strategies including drafting, delivering, and ensuring timely execution of contracts.
- Develop and analyze all contract rates to ensure budget objectives are met.
- Oversee the negotiations for Letter of Agreements and administer the Agreements.
- Negotiate Provider contracts for the provision of all covered benefits including physicians, behavioral health, ancillaries, IPA’s and hospital agreements.
- Oversight responsibility for the Contract Administration unit including contract development, processing and maintenance of the Agreement.
- Oversee the orientation and maintenance of ancillary and facility contracts by conducting hospital JOM’s and in-servicing providers as necessary to fully serve our members as contractually required. Additionally, assist in claims reconciliation issues between the Claims Department and contracted providers.
- Work with the Executive leadership team regarding strategy, program development, provider recruitment, contracting and onboarding initiatives.
- Development of an adequate provider network in assigned geographical areas.
- Maintaining relationships and all provider relations activities in assigned geographical area until transition to Local Network is completed.
- Monitor performance, develop, and implement business solutions to address process and quality gaps, and communicate network strategy and planning.
- Ensure compliance with CMS, State, Federal regulations, as well as company Policies and Procedures and legal requirements.
- Collaborate inter-departmentally to ensure contracts are implemented effectively throughout the health plan including Provider Services, Claims and Medical Services.
- Participate and implement LEAN processes throughout the Provider Contracting Department to eliminate waste and create operational efficiencies.
- Supervisory Responsibilities Leader : Administers Hires, Terminations, and Performance Reviews.
- Ability to travel as needed.
- Special projects as assigned.
Minimum Qualifications
Professional Competencies
Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!
Job Type : Full-time
Onsite : 100% onsite
Benefits :Schedule :
Ability to commute / relocate :
PHYSICAL DEMANDS
Regularly sit / walk at a workstation in an office or cubicle setting. Must occasionally lift and / or move up to 25-50 pounds.
Other duties may be assigned in support of departmental goals.
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