Lead Director, Network Management (Oklahoma)

CVS Health•Tulsa, OK

About The Position

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Position Summary The Lead Director will manage the development of contracts and agreements with providers and delivery systems in conjunction with being accountable for designing conceptual models, initiative planning, and negotiating high value/risk contracts with the most complex and challenging, market/region/national, largest group/system or highest value/volume of spend providers in accordance with company standards in order to maintain and enhance provider networks, while working cross functionally to ensure consistency with all contracting strategies and meeting and exceeding accessibility, quality, compliance, and financial goals and cost initiatives. Negotiates and executes, conducts high level review and analysis, dispute resolution and/or settlement negotiations of contracts with larger and more complex, market-based, group/system providers. Manages contract performance and supports the development and implementation of value-based contract relationships in support of business strategies. Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review analysis of reports as part of negotiation and reimbursement modeling activities. Responsible for identifying and managing cost issues and initiating appropriate cost saving initiatives and/or settlement activities. Assists with the design, development, management, and or implementation of strategic network configurations and integration activities. Drives or guides development of holistic solutions or strategic plans negotiates and executes contracts with the most complex, market /region/national, largest group/system or highest value/volume of spend providers with significant financial implications. Recruits providers as needed to ensure attainment of network expansion and adequacy targets. Accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities. Responsible for identifying and managing cost issues and collaborating cross functionally to execute significant cost saving initiatives. Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners. Evaluates, helps formulate, and implements the provider network strategic plans to achieve contracting targets and manage medical costs through effective provider contracting to meet state contract and product requirements. Collaborates with internal partners to assess effectiveness of tactical plan in managing costs. May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met. Ensures resolution of escalated issues related to contract interpretation and parameters. Interprets contractual requirements including federal and state regulations and NCQA. Participates in JOC meetings. Promotes and educate providers on cultural competency. Sets specific, challenging and achievable objectives and action plans. Manages complex, contractual relationships with providers according to prescribed guidelines in support of national and regional network strategies. Mentor and coach new/more junior staff to educate and inform on accreditation and regulatory standards as well as policies on credentialing and re-credentialing.

Requirements

10+ years of related healthcare contracting experience.
Expert-level negotiation skills.
Proven track record of successfully negotiating contracts with large, complex national providers and vendor organizations.
2+ years of people leadership experience.
Demonstrated ability to lead, develop, and influence high-performing teams.
Strong knowledge of provider financial management.
Strong knowledge of competitive market strategies.
Strong knowledge of complex contracting methodologies.
Strong knowledge of value-based and risk-based arrangements.
Strong knowledge of applicable regulatory requirements.
Demonstrated success identifying and leading initiatives that improve total cost of care, enhance quality outcomes, and drive organizational performance.
Extensive experience within a health plan, payer, or provider system environment.
Deep understanding of healthcare delivery and reimbursement models.
Bachelor's Degree required or a combination of professional work experience and education.

Nice To Haves

Experience with Medicaid regulatory requirements.
Demonstrated knowledge of compliance standards and state-specific program guidelines.
Strong background in Medicaid provider contracting and implementation.
Experience with contract development, negotiations, and network setup activities.
Excellent communication, critical thinking, problem-solving, and interpersonal skills.
Ability to collaborate effectively across cross-functional teams and stakeholders.
Hands-on experience configuring and maintaining provider and vendor contracts within core Aetna Medicaid systems, including QNXT.
Direct experience working with providers in Oklahoma.
Understanding of Oklahoma's Medicaid market and provider landscape.
Working knowledge of value-based care and alternative payment arrangements.
Knowledge of value-based contracting principles and performance-based reimbursement models.

Responsibilities

Manage the development of contracts and agreements with providers and delivery systems.
Design conceptual models and plan initiatives.
Negotiate high value/risk contracts with complex providers.
Maintain and enhance provider networks.
Ensure consistency with all contracting strategies.
Meet and exceed accessibility, quality, compliance, and financial goals.
Negotiate and execute contracts, conduct high-level review and analysis, dispute resolution, and settlement negotiations.
Manage contract performance and support value-based contract relationships.
Recruit providers to meet network expansion and adequacy targets.
Accountable for cost arrangements within defined groups.
Collaborate cross-functionally to manage provider compensation and pricing development.
Submit contractual information and review/analyze reports for negotiation and reimbursement modeling.
Identify and manage cost issues and initiate cost-saving initiatives or settlement activities.
Assist with the design, development, management, and implementation of strategic network configurations and integration activities.
Drive or guide the development of holistic solutions or strategic plans.
Represent the company with high-visibility constituents.
Promote collaboration with internal partners.
Evaluate, formulate, and implement provider network strategic plans.
Assess the effectiveness of tactical plans in managing costs.
Optimize interaction with assigned providers and internal business partners.
Ensure resolution of escalated issues related to contract interpretation and parameters.
Interpret contractual requirements, including federal and state regulations and NCQA.
Participate in JOC meetings.
Promote and educate providers on cultural competency.
Set specific, challenging, and achievable objectives and action plans.
Manage complex contractual relationships with providers.
Mentor and coach new/more junior staff on accreditation and regulatory standards, and credentialing/re-credentialing policies.