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Vice President – Provider Contracting and Service
Vice President – Provider Contracting and Service
AvMed is a Florida not-for-profit (IRC Section 501(c)(4)) corporation established under Chapter 617, Florida Statutes, and regulated under Chapter 641, Florida Statutes. AvMed’s Mission, “To help our members live healthier,” and Vision, “To be our members’ trusted health partner for life,” is achieved through serving 300,000 members through underwritten and self-funded Commercial Groups, Individual Products and Medicare Advantage Plans. AvMed is headquartered in Miami, Florida, and maintains regional offices in Ft. Lauderdale, Orlando, Tampa, Gainesville and Jacksonville.
The Vice President (VP) – Provider Contracting and Service has overall responsibility and accountability for effectively and efficiently leveraging technology and people in delivering a unique and differentiating member (and aligned provider) experience through Strategic Orientation. Works in tandem with the SVP, Chief Medical Officer, Population Health and Provider Alliances and other senior executives in the Company in defining the market’s overall and network strategy, in developing its competitive position, identifying key medical cost containment opportunities and has accountability for the successful execution of each. Contributes strategic thinking to help position the network organization for the future, and identify emerging market demands and changes. Establish strategies to achieve competitive positioning in the market against national, regional and local competitors in unit cost, access and availability, and provider satisfaction. Maintain an in-depth and comprehensive knowledge of competitor provider networks in the applicable geographies including the delivery models, financial viability, network participants, professional issues, services, availability, quality, and ethnicity, etc.
Network Contracting - Responsible for establishing and monitoring an annual unit cost and network operating plan for the market by line of business and medical service for all lines of business; gains market intelligence and uses internal information to ensure that the network is market competitive in geographies of accountability. Creates the approach for and leads complex provider negotiations with geography-specific high volume, Tier 1 hospitals and very large medical groups that include a variety of methodologies, including capitation and risk, in accordance with AvMed’s provider contract standards, unit cost and trend targets, reimbursement structure, and strategic objectives. Lead the market effort in identifying practice and utilization patterns, and profiling to move to value-based reimbursement methodologies based cost-effectiveness and quality parameters. Identify opportunities for coaching and continuous improvement of providers through the review of profiling and data analysis.
Lead the market in the negotiation and oversight of several high spend delegated providers and vendors. Ensure that the delegated providers and or vendors are high performing and are meeting their cost, quality and service and performance benchmarks. Oversee and participate in the implementation of these agreements and the development of ongoing joint operating committees and subcommittees.
Lead the market in developing unique networks for ASO clients and for new Commercial fully insured products. In tandem with other executives, use data to evaluate network tiers and benefit designs and new products that promote optimal medical unit costs.
Lead the development of provider education materials and the work streams for provider education. Work with other executives to evaluate and adopt new technologies that will enable the desired provider and member experience.
The successful VP will be detail oriented, tenacious and possess strong strategic, communication, negotiation, financial and analytical skills to ensure a program of the highest quality, which will result in optimal outcomes for members, providers, and the Company. He or she will be experienced and proficient in emerging provider payment methodologies, Accountable Care Organization’s principles, and the development of strategies to support these endeavors. The VP will also have the level of professionalism, credentials, and credibility to interact and influence C-Suite and Senior Executives of Hospitals, Medical Groups, and key community and trade organizations.
Oversee the handling and documentation of all state-wide provider complaints received through the Provider Service Center. Work with Manager, Provider Service Center to review and track ageing cases and assist with resolution time. Support the improvement of performance in the Provider Service Center by raising efficiency and the use of new technology and equipment to enhance productivity. Ensure escalation of provider service issues to Provider Service Liaison and timely resolution and response. Ensure appropriate handling, resolution, and education of member grievances against providers. Work with the Manager, Provider Service Center to ensure that KPI goals are met and reported out monthly.
The success of the VP – Provider Contracting and Service will be measured by his/her ability to lead these critical Provider Contracting and Service functions in realizing AvMed’s service philosophy, “We create peace of mind by inspiring confidence and building trust through everything we do” and aligned with the following guiding principles:
• The member is the customer;
• We will attract, engage, manage and retain our members across the health care continuum; and
• Engage aligned providers to deliver the optimal health and wellness experience.
KEY REPORTING RELATIONSHIPS
The VP – Provider Contracting and Service reports to the:
• SVP, Chief Medical Officer, Population Health and Provider Alliances
• Works in unified and cohesive collaboration with the Senior Vice Presidents responsible for AvMed’s core and enabling functions, as follows:
• Core Functions – Product Life Management (PLM) & Innovation; Member Relationship Management; Provider Strategy & Alliances; Member Health & Wellness; Delivery Solutions;
• Enabling Functions – Finance & Treasury Services; Information Technology; Human Resources; and Legal & Compliance.
Reporting directly to the VP – Provider Contracting and Service are: Two (2) Directors, Hospital/Ancillary Contracting and Service; one (1) Manager of Delegated Providers; Two (2) Managers of Physician Provider Contracting.
Provider Contracting and Service is currently comprised of approximately 13 associates.
• Ensure optimal member (and aligned provider) experience through Network and Service.
• Instill and motivate a broader cultural desire across the organization to focus on the member, with the objective of consistently improving member (and aligned provider) experience metrics for Network and Service.
• In collaboration with the SVP and SVP-HR, responsible for Leadership Development and Talent Management of Provider Contracting and Service associates, including establishing a leadership climate that contributes to a highly engaged and diverse workforce committed to AvMed’s Vision, Mission, Values, Core Beliefs, Service Philosophy, and Service Standards.
Business Operations and Results
• Oversee and ensure that Provider Contracting and Service has the proper technology and operational systems and controls, administrative and reporting procedures, and talent processes in place.
• Work collaboratively with the SVP & SVP - CIO in ensuring all Provider Contracting and Service technology and business applications are maintained and upgraded in accordance with IT standards, including version control, etc.
• Develop and maintain strong relationships with all key vendors that support Network and Service, while holding vendors accountable for delivering upon their contractual commitments.
• Facilitate tradeoffs and make decisions on the design and delivery of the member experience through Provider Contracting and Service based on alignment with strategy, cost and ability to execute.
• Review, approve and manage the Provider Contracting and Service annual operating and capital budgets within industry standards and best practices in order to maintain an affordable and efficient cost structure.
• Monitor and manage monthly financial and other key performance metrics.
• Work in collaboration with the SVP and other senior executives to achieve the strategic and operational objectives of AvMed.
• Overall responsibility and accountability for organizational leadership and performance within Network and Service.
• Work in collaboration with SVP to develop, implement and achieve the strategic, operational and financial objectives.
• As an executive, working with the SVP – Member Relationship Management, take a proactive and engaged role in the identification and conversion of prospective members and clients.
• Represent AvMed externally and convey a professional and positive image.
• Participate in Strategic and Operational Committees, as appropriate, for carrying out organizational strategic plans, operations and policies.
Corporate Assurance & Compliance
• In collaboration with Chief Assurance Executive, Chief Compliance Officer and Director of Financial Controls, ensure effective corporate assurance, risk management, compliance functions and financial controls within Network and Service.
• Ensure Provider Contracting and Service meets all applicable regulatory, statutory and compliance rules and regulations.
• Ensure Provider Contracting and Service meets all applicable accreditation requirements.
Community and Industry Involvement
• Maintain a visible leadership role in appropriate Industry, Professional and Community organizations.
• As appropriate, represent AvMed externally to clients, providers, regulators and other constituents as relates to Network and Service.
Policies and Procedures
• Ensure policies, procedures, rules and regulations necessary and desirable for the proper conduct of ordinary affairs of Provider Contracting and Service are established, maintained and followed.
• Perform other related duties as assigned by the SVP.
Mission Driven - Alignment with the AvMed mission, vision, values, core beliefs, service philosophy and standards.
Education – Bachelor’s degree in business administration or related major required. Master’s MBA/MHA/MS degree or equivalent experience preferred.
Experience – Minimum of ten (10) years’ experience in a complex and diversified health care/health insurance company. Previous managed care experience preferred but will consider those with integrated system contracting background.
Steward of the Business – Drives AvMed’s Strategy and owns the business. Clear understanding of organization, industry, constituents, and competitive markets. Sound business judgment. Service excellence mindset.
Delivers Results – Delivers strong business results. Sets and achieves challenging goals. Contributes towards achievement of corporate objectives. Cultivates a culture of accountability and sense of urgency.
Leadership Excellence – Sets the example for living The AvMed Way. Proactively shapes the desired organizational culture. Inspires, appreciates, and empowers others. High emotional intelligence.
Communication and Influence – Communicates clearly and confidently. Listens, writes, and speaks effectively. Shares important information. Motivates action and commitment.
Leads Change – Inspires, leads, and executes organizational change. Continuously challenges the status quo. Role models adaptability. Gains buy-in for change efforts.
Strategic Perspective – Thinks “big picture.” Understands broader context of the business. Anticipates what’s ahead. Recognizes how leadership role drives organizational objectives.
Maximizes Effectiveness – Helps others perform at their best. Builds a high performing team. Proactively engages and retains staff. Strong, positive relationships with others.
Time: Full time
Updated: 2/15/2019 10:26:28 AM