Job Brief

Must reside in South Carolina to qualify for favorable consideration.

Responsibilities:

This role provides strategic direction for Provider Network value-based contracting across the Plan, acting as the Select Health South Carolina subject matter expert for VBC for internal Plan counterparts and members of the Plan’s provider network community. Reporting to the Director of Provider Programs and Payment Innovation, as a member of the Corporate Provider Network Practice Transformation Team, the Manager, Market Value-Based Contracting Program will develop, implement, and manage the Plan network’s value-based reimbursement strategy in concert with Corporate Provider Performance (CPP) team. In partnership with each of the Plan’s Directors and Managers of Provider Network Management, the incumbent will be responsible for managing all assigned hospital, physician and physician extender value-based program development and management, formulating, and implementing alternative reimbursement methodologies for various provider types that ensure the financial performance of the network. Partnering with the Plan’s directors and Managers of Provider Network Management, interacts with Hospital and Physician Practice Chief Executive Officers, Chief Financial Officers, Directors of Managed Care and other high level executives, facilitating, executing and communicating contract negotiations with regard to value based contract needs. The incumbent will partner with CPP and Plan SMEs on development of alternative payment methodologies and strategies at a Plan level. Collaborate with internal and external support and stakeholders to integrate value-based reimbursement strategies into Plan’s provider network management framework. Ensure research, structures and expertise is in place to allow new innovative payment methodologies to flourish on an ongoing basis. Ensure the provider network and internal staff achieves annual goals and objectives.

Partnering with the Plan’s Directors and managers of PNM, carries out Provider network management leadership responsibilities including:

• Strategic planning of hospital and physician network value based contracting development and management.
• Compliance with value based contracting pricing guidelines.
• Ensures provider value-based contracting is consistent with program payment methodologies.
• Maintains familiarity with State Medicaid fee schedules and analyzes comparable value-based programs from other payors.
• Ensures provider value based contracting policies are adhered to as related to standard contract language.
• Ensures that non-standard value-based contract elements are communicated appropriately and approved.
• Ensures capitation, RHC/FQHC reports are monitored, and strategies are developed, and plans are implemented to address outliers.
• Assists territory Account Executives with planning, implementing, and monitoring value-based programs.
• Assists territory Account Executives in determining underperformers and meet with them to discuss improved care.
• Ensures the achievement of financial, quality, and clinical objectives through accomplishment of value-based provider initiatives.

Education & Experience:

• Bachelor's degree in Business or Health related disciplines such as Healthcare Administration or Healthcare management or equivalent business experience.
  
• Minimum 5 years of progressive business management and negotiation experience, managing projects.
• A minimum of 3 years Managed Care Provider Contracting and Reimbursement experience, at an independent high-dollar contracting level, focusing on value based and innovative payment methodologies.
• Proven financial modeling skills and the ability to communicate complex concepts at all levels.
• Proven influencing skills with internal and external stakeholders.
• People and team management experience preferred.
  
• 1 to 2 years Medicaid experience preferred.
• A valid Driver’s License and current Auto Insurance required.
• Remote- Must Reside in South Carolina