Details
Posted: 11-May-22
Location: Portland Metro Area, Oregon
Salary: Open
Overview
The overall purpose of the Provider Contract Manager 2 position is to effectively manage an assigned portfolio of NWP, KFH and KFHPNW contracted provider relationships in a manner consistent with (1) NWP's objectives, (2) KFH and KFHPNW's objectives, (3) NCQA, JCAHO, and other accreditation requirements, (4) applicable federal and state laws and regulatory requirements, (5) meets the Care Delivery needs of KFHP-NW's Members, and (6) upholds the business, finance, regulatory and reputational interests of KPNW.
Join our medical group
Northwest Permanente is a self-governed, physician-led, multi-specialty group of 1,500 physicians, surgeons, and clinicians, caring for 630,000 members in Oregon and Southwest Washington. Kaiser Permanente is one of the nation's preeminent health care systems, a benchmark for comprehensive, integrated, value-based, and high-quality care.
Responsibilities
Major Responsibilities / Essential Functions
Network Development
Identifies and/or anticipates outside medical care service needs and opportunities to complement Region's overall care delivery. Collaborates with Finance and Operations leaders, Senior Practice Directors/Sr. Administrators, Practice Directors/Dept. Administrators, Physician Chiefs, Sr. Director and Director of Provider Contracting and MD VP, Business Affairs to develop contracting strategies. Develops and maintains relationships with internal and external care providers. Participates in community relations activities to enhance the image and reputation of the organization. Successfully negotiate contracts that achieve cost reduction or other contract and relationship maximization. This includes facilities, individual and group medical practices, using a diverse range of techniques and contracting 'best practices', to include DRG's, per diems, case rates, and other industry standard payment methodologies. Negotiate key financial and operational terms with hospitals, physicians and ancillary providers in a manner consistent with market strategy utilizing approved contract templates, approved reimbursement methodologies, KP clinical needs and standards, and applicable laws and regulations. Ensure negotiated terms are accurately and thoroughly documented in contractual agreements in order to mitigate financial or legal risk to the organization. Work closely with care delivery partners, analytics, finance, sales and marketing, claims, UM, credentialing, member services, membership administration, benefits administration, legal, regulatory and medical group leadership to implement contracting options on time and within budget. Develop and quantify strategic options for network development and expansion including, but not limited to: - Identifying contract options and targeted providers
- Establishing short- and long-range contractual terms
- Developing pricing models across multiple facilities, service lines, service levels and programs
- Maximizing contract leverage
- Preparing reports on the cost of contracted services
- Identifying trends and then using a team-based approach to evaluate options for change
Contract Performance
Monitor contract performance to ensure compliance with contract terms and conditions. Collaborate with Care Delivery (Practice Directors, DA's, Chiefs) in the ongoing clinical, operational and business management of external provider relationships. Coordinate implementation of new contracts as well as administration of existing contracts; work with Provider Relations and Care Delivery partners to assure smooth transition from contracting to service activities. Negotiate and facilitate resolution of complex care delivery, claims payment, utilization management, credentialing and/or other operational issues with provider. Monitor external healthcare delivery marketplace and internal utilization trends. Assess new opportunities for cost savings, alternative delivery models and financial risk sharing. Contract Compliance
Work with Legal, Regulatory and Compliance to assure that contract templates are compliant. Ensure that contracts can be administered within KPNW systems (e.g., Claims payment). Meet all regulations related to the sphere of contracting. Coordinate with Provider and Quality Resource Management Department to ensure timely credentialing of all providers prior to contract being effective. Coordinate with Director, Provider Contract Analytics and Reimbursement, and other KFH/KFHP-NW and NWP Finance staff to develop analyses and payment strategies that will result in cost effective contracts. Coordinate with Provider Configuration to assure that all contracts are loaded accurately and in a timely manner and to avoid negative impact on claims performance due to retro contracts or inaccurate configuration. Qualifications
Minimum Education
- Bachelor's degree or equivalent experience in business, finance, healthcare administration or related field.
Minimum Work Experience
- Minimum three (3) years progressive responsibility and quantifiable results in network development and delivery system negotiations, with experience contracting for multiple managed care products including HMO, PPO, POS, EPO and multiple funding options including fully insured and self-funded plans.
- Strong influencer; demonstrated contributor to building and upholding a positive team culture.
- Strong financial acumen - must possess extensive knowledge of hospital, physician, skilled nursing, and ancillary provider reimbursement models for commercial and government payers, including pay for performance models.
- Knowledge of network development, provider network clinical and business operations, provider relationship management, reimbursement analysis, contract performance analysis.
- General knowledge of legislative and government activities and marketplace issues affecting the region preferred.
- Comprehensive knowledge of Medicare and Medicaid payment methodologies, level of care pricing, and federal and state health care regulations.
- Demonstrated knowledge of and skill in adaptability, change management, conflict resolution, customer service, decision making, influence, negotiations, interpersonal relations, oral and written communication, prioritization, problem solving, quality management, systems thinking, teamwork, time management, leadership, facilitation and project management.
- Must be a "self-starter" with a strong sense of initiative and follow-through. Ability to work independently under high-pressure circumstances with little or no supervision.
- Software skills including Microsoft Word, Excel, PowerPoint, Access, Project, and Visio preferred.
Additional Requirements
- Budget Responsibility: The Provider Contract Manager has no direct KPNW operating budget responsibility, per se, since the contracts contemplate services that are part of the overall budget responsibility of a NWP Service Chief/Practice Director or a KFHP Operations Leader (e.g. the Director of Continuing Care Services). It should be noted, however, that the Provider Contract Manager has significant influence on KPNW's operating budget in their ability to negotiate cost-effective financial terms and payment strategies.
- Ability to negotiate cost effective contracts to meet operating budget targets in an environment where KPNW holds little to no leverage, and provider relationships are challenged due to KPNW's internalization and integrated care delivery strategies.
- Ability to meet operating budget targets.
- Able to handle the constant pressure of multiple simultaneous projects with competing priorities and deadlines.
- Due to the demands placed upon the Provider Contracting Department, the pace is rapid and dynamic, sometimes causing project priorities to rapidly and significantly shift. Ability to work in a high pressure environment with sometimes limited resources while expected to meet aggressive project timelines.
Internal Project Team Skills
- Ability to develop & maintain trusting relationships with internal KPNW staff and leadership.
- Ability to listen to KPNW Clinical Leadership's care delivery needs in contracted provider relationships and associated operating budget constraints, and to translate these needs into an effective contracted relationship.
External Practitioner/Provider Skills
- Ability to develop & maintain trusting relationships with contracted providers (Physicians, Physician Administrators, Hospital CEO's, COO's and CFO's.
- Ability to consistently and effectively negotiate sound contracts with targeted providers utilizing astute management of each stage of the negotiation; appropriately escalating outstanding business and clinical issues to leadership.
- Ability to work effectively and diplomatically with the leadership of contracted providers to address contract interpretation, performance, and enforcement issues.
- Ability to work effectively and collaboratively with representatives from other NWP and Health Plan departments, and/or other KP regions.
- The stress level can be above average at times due to the difficulty of negotiating provider contracts within prescribed deadlines and operating budgets.
- In order to meet with physicians, providers and/or other administrative staff when they are available, there are frequent early morning and early evening meetings.
- Position will require some overnight travel around the Pacific Northwest.
- Position will require accessing some non-Kaiser provider offices which may not be ADA accessible.
Required Licensure, Certification, Registration (LCR)
- Valid Oregon and Washington driver's license and active auto insurance.
Preferred Education
- Master's degree in business, finance, healthcare administration or a related field, or equivalent combination of education and experience.
Preferred Work Experience and Qualifications
- Minimum five (5) years progressive responsibility and quantifiable results in network development and delivery system negotiations, with experience contracting for multiple managed care products including HMO, PPO, POS, EPO and multiple funding options including fully insured and self-funded plans.
- Extensive knowledge of network development, provider network operations, provider relationship management, reimbursement analysis, contract performance analysis required.
- Comprehensive knowledge of legislative and government activities and marketplace issues affecting the region.
Equal opportunity employer
At Northwest Permanente, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants without regard to race, color, religion, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military and veteran status, and any other characteristic protected by applicable law. Northwest Permanente believes that equity, inclusion, and diversity among our employees are critical to our success, and we seek to recruit, develop, and retain the most talented people from a diverse candidate pool.
