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Director of Provider Relations and Provider Contr

Job Summary:

This role is responsible for all aspects of management, maintenance, development, expansion and optimization of Piedmont’s provider networks, except for contract negotiation as detailed below, regardless if the networks are direct-contracted or accessed via agreement with third-party network providers (such as Aetna First Health, Aetna ASA or Virginia Health Network).

This role is expected to be the face of Piedmont with other health systems. Therefore, duties will include elements of relationship management, process management, contract adherence, problem solving, and project management. Our vision is to evolve partnerships between Piedmont and health systems across Virginia from transactional to strategic in nature, from insurance-based to multi-product based, and from fee-for-service based to value-based in design. This role is expected to lead or participate on the multi-departmental teams which will be involved in these transformational initiatives.

This role will not, initially, be responsible for Piedmont contract negotiation with non-participating providers due to the specialized nature of this skillset. However, this role will direct and oversee the activities of the negotiator (who will be a hired consultant). Further, It is expected that this job holder will, over a defined period of time, develop the necessary competencies to expand into and take over the direct provider contract negotiating role.

Note: The term “provider network” is intended to all medical entities to which Piedmont pays claims, including directly contracted independent providers, directly contracted provider groups, directly contracted facilities, directly contracted health systems as well as like entities contracted through third-party network providers.

This role also owns Piedmont’s provider data management process (post credentialing) which ensures that accurate and up-to-date information concerning our providers is secured and then provided to users (including our claims processor, our provider directory and our provider search tool).

Finally, at the time when Piedmont chooses to commercialize our direct network (i.e. lease or otherwise make our network available to other payors), this role will be responsible for developing, recommending and, if approved, administering those efforts.

Key Job Responsibilities include:
• Development of a network contracting strategy aligned with market objectives.
• Development and execution of a work plan to implement network contracting strategy.
o Provide contract development, administration, and oversight of delegated contracting and network management functions and analytics.
o Ensure contract adherence.
• Meet with provider organizations to discuss contracting approach, invite discussion, and work collaboratively to progress in the contractual relationship.
• Lead efforts, possibly along with outside experts, to evaluate rates and develop repricing and reimbursement strategies; work with colleagues/staff to implement agreed recommendations.
• Negotiate and execute contracts, possibly along with outside experts, in fee for service and value-based arrangements.
• Lead efforts for strategic provider rate reimbursement and value-based arrangements.
• Leads all efforts associated with the provider data management process.
• All other duties as assigned.

Required competencies include:
• Relationship development.
• Financial analysis/assessment.
• Contract management.
• Problem-solving.
• Negotiation.
• Understanding and knowledge of advanced value based contracting mechanisms.
• Ability to seek out, build, and nurture strong internal and external professional relationships with coworkers and provider partners, requiring skill in tactful and diplomatic discussions with ability to articulate valuable insights and explanations to advance the relationship
• Knowledge of health insurance operations, healthcare financing, reimbursement mechanisms, commercial and government health plan products, and healthcare analytics

• Bachelor’s degree required.
• Master’s degree preferred.
• 7+ years in leadership HR roles is required.
• Experience in account management is preferred.

Certification/Licensure Requirements

Time:  Full time
Salary:  Salary
Category:  Administration

Updated: 1/19/2021 1:04:20 PM

Job Contact:
Neil Heller

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2316 Atherholt Road
Lynchburg, VA 24501