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Years of Experience
Date Last Verified
Director, Contract Development and Standards The candidate will oversee provider contracting development and standardization area with responsibility encompassing all commercial and government network participation contracts and innovation, population health and value-based payment contracts, and credentialing processes. Will monitor evolving trends in the industry to ensure that provider contracts and network participation standards remain current with reimbursement methods, administrative changes and compliance requirements to mitigate negative financial and provider relation impacts. Oversight of the organization and maintenance of all contract templates; identification and evaluation of actual or potential exposures to corporate financial, legal and regulatory risk which may result from provider contracting revision and credentialing efforts; and mitigation of provider disputes through disciplined processes and contracting and credentialing standards, while assuring all mandated requirements, whether legislative or otherwise, are met. Develop and execute a multi-year strategy to maintain and update core contracts, through feedback from internal stakeholders, external industry trends and trusted providers, to reduce the administrative burden associated with our current legal documents. Evaluate and, where needed, develop solutions to address gaps in contracting and credentialing process controls. Complete and develop a long-term strategy to maintain the digitization and associated corporate training to secure our provider contracts and provide access to the broader corporation, as appropriate. Collaborate with Provider Network Contracting (PNC) area to test and refine our current negotiation and escalation processes to better support our negotiation teams. Develop an annual budget and direct within budget parameters and guidelines. Develop and manage key internal relationships with peer executives across all functional areas to ensure contracts are current with changing business requirement. Evaluate and implement, when appropriate, new and innovative approaches to contracts that optimize reimbursement structure and increases administrative simplification. Coordinate and collaborate with PNC team on high profile provider negotiations and mass network initiatives. Oversee and implement changes to contracting and credentialing processes consistent with state and federal laws and regulations for all lines of business. Coordinate and collaborate with appropriate parties to ensure contracts are consistent with current law, best practices and corporate policies. Ensure that the contract process includes Legal Division, Actuarial, Business Engineering and Claims consultation when appropriate.
Qualification and Experience
The candidate should have Bachelorâ€™s degree in Business Administration, HealthCare Management, or a related field required. JD degree is highly preferred. Experienced transactional/contracts paralegal or equivalent managed care contracting is required. 5+ years of contracting experience required. Should have 2+ years of experience in health care law. 5 years of leadership/management experience required. Direct experience with provider contracting is preferred. Understanding of health care reimbursement methodologies, e.g., CMS, Resource-based Relative Value System, Ambulatory Surgery Center Grouper is essential. Understanding of the BlueCross Association requirements that govern provider contracts through the BlueCard System is essential. Knowledge of federal and state government contracting and insurance requirement is essential. Knowledge of Tennessee laws and regulations that govern the development and execution of provider contracts is essential. Knowledge of accrediting and regulatory standards (i.e. NCQA, HHS, CMS, EQRO and Division of Tenncare) is essential. Should be proficient in Microsoft Office (Outlook, Word, Excel and PowerPoint). Strong interpersonal and organizational skill is essential. Excellent written and verbal communication skill is essential. Experience using MS Word and styles is essential.
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