Lead Director, Provider Performance Value-Based Care

The Lead Director of Value-Based Contracting is responsible for establishing and maintaining productive value-based relationships with key network providers. Responsible to develop and manage the Keystone Value-based Network as outlined below:

• Accountable for building strategic relationships with our provider partners to develop innovative value-based solutions to meet total cost and quality goals.

• Responsible for developing alternative payment models, identifying and planning new initiatives, and negotiating high value/risk contracts with the most complex arrangement structures, which requires:

  • understanding providers’ volume and cost structure

  • working cross functionally to identify the levers and critical negotiation points

  • aligning negotiation strategies and tactics with network accessibility, quality, compliance and financial performance goals

• In charge of complete value-based contracting cycle from planning, creating documents, negotiation and loading of executed arrangements.

• Works with Performance team, Clinical Transformation team, VBS Analytics team and other key internal teams to develop a value-based strategic plan and oversee contract performance with targeted provider groups to ensure we meet objectives for value-based provider agreements.

• Evaluates, helps formulate, and implements network strategic plans to achieve value-based contracting targets and manage medical costs through effective value-based contracting.

• Provides assistance and support to other departments, as needed, to obtain crucial or required information from providers, such as HEDIS, Credentialing, Grievance and Appeals, SIU, etc. Coordinates provider status information with member services and other internal departments.

• Leads work and deliverables of complex projects/programs, through assessment to implementation, that may impact multiple processes, systems, functions, and products across all lines of business.

• Facilitates and attends external provider meetings and negotiations, as needed.

Required Qualifications

• 10 years of related experience and comprehensive level of negotiating skills with successful track record negotiating value-based contracts with IPAs, large complex provider systems or groups. hospitals and large physician entities

• Experience reviewing medical claims data and developing executive summaries and identifying opportunities for mitigating medical cost trend

• Excellent analytical and problem-solving skills

• Strong communication, negotiation, and presentation skills

• Ability to work in a matrixed organization and gain consensus and share information to various interested parties.

Preferred Qualifications

• Familiar with legal terms in the context of provider contracting.

• Familiar with CMS Stars and HEDIS technical specifications and various measurable percentiles associated with the HEDIS measures.

• ​Experience with Commercial, Medicare and Medicaid contracting.

• Able to apply system thinking when managing multiple provider value-based initiatives

• Strong financial modeling background

Education

• Bachelor’s degree preferred or a combination of professional work experience and education.