Director of Provider Contracting

Department: Contracting

Job Summary:
Oversight and ongoing development of Provider Contracting Department. Current staff consists of 8-10 employees with the potential for growth. This high profile position is responsible for the management of an operating budget, quality results, contracting compliance, network effectiveness, medical loss ratio's for each IPA; productivity and staff development while ensuring delivery of quality service results to over 70,000 providers and 240,000 members spanning 4 counties in Southern California. Position includes strategic planning and network development for over 13 IPA's and 25 hospitals in a highly competitive market. Duties also include integration of ongoing acquisitions with a focus on contract consolidation and cost containment through capitation arrangements, focused on technology initiatives for efficiency, accuracy and process improvement. Working knowledge of federal and state legislation related to network development, provider services and managed care entities, including Department of Managed Health Care, Centers for Medicare/Medicaid, and Department of Health Services.

The following job functions are included, but not limited to:

  • Administer the appropriate cost and service measurements (metrics, measures and controls) to ensure the achievement of all key performance objectives that impact Prospect's profitability and position in the marketplace
  • Responsible for driving and reinforcing the leadership cornerstones of redefining quality, aligning accountability and enabling people
  • Direct overall operations, determine performance objectives/metrics with input from senior management, define/develop the tools needed to measure progress and ensure consistent achievement of business objectives and medical loss ratio's by IPA
  • Develop a climate for the fulfillment of Quality Service through strategic alliances with all business units and external customers
  • Collaborate with senior management of support departments (Medical Management, Customer Relations, Marketing and Claims) to manage expectations, reduced expense, priorities, workflows and ensure best results for the organization
  • Highly skilled in analysis of metrics and performance measures for high volume specialties, including cost containment through capitation with key partners in high service areas
  • Readily familiar with delegation requirements related to Members and Physicians, including but not limited to regulator bodies such as DMHC, DHS, and CMS
  • Oversee annual contract review with general counsel for compliance, including review by appropriate functional areas within the organization, and ensures operational effectiveness of contracts
  • Participate in strategic efforts to conclude acquisitions with the goal of integration into the core operations, in a supporting role. This includes network analysis and cross mapping of required specialists according to the DMHC minimum network requirements and appropriate contract consolidation for improved claims costs.
  • Lead direct report team (Manager of Contracting and Senior Contract Administrators) to create and manage a business and financial plan for reduce medical cost ratios, periodically re-forecast against actual results with the assistance of finance and ensure appropriate financial contributions to the overall plan
  • Partner with Senior Management and Human Resources on all leadership initiatives including compensation planning, performance management, turnover and retention planning, staffing and employee relations concerns/issues, employee recruitment, employee development, organizational design and strategic planning initiatives
  • Develop, motivate, attract and retain top talent for succession planning
  • Responsible for the development and ongoing maintenance of internal controls for compliance with Sarbanes-Oxley

Requirements and/or Qualifications:
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • 10+ years of experience in the healthcare industry
  • 5+ years of experience in managing a large IPA with extensive provider network
  • 5+ years of experience negotiating complex contracts for various providers including hospital, ancillary, primary care, and specialty care services for all divisions of responsibility
  • 5+ years of experience negotiating capitation contracts for high volume specialists including the development and analysis of costs associated with defined specialties and applicable carved out services
  • 5+ years of experience with operations management and quality methods in a process and/or service environment
  • Proven success in improving key performance metrics
  • Demonstrated success in process improvement, cost reduction and improving efficiencies
  • Demonstrated leadership skills, ability to coach, mentor and foster a culture of continuous learning, empower and motivate others
  • Strong independent decision-making, influencing and analytical skills
  • Extensive knowledge of managed care guidelines and regulations for delegated models, including all lines of business
  • Excellent operational skills to ensure appropriate implementation of negotiated contracts in conjunction with support departments such as Claims and Fee Schedules for improved provider satisfaction
  • Excellent negotiation skills including experience in healthcare informatics or related data analysis experience
  • Excellent written and verbal communication skills, training, project management, including complex word processing and spreadsheet skills
  • Attention to detail and ability to handle multiple tasks simultaneously including a high volume workload
  • Application of appropriate interventions and follow up on identified issues/projects
  • Maintain a positive attitude with changing conditions
  • Ability to work effectively under pressure by prioritizing work activities

Education and/or Experience:

  • Bachelor's degree required, advanced degree preferred
  • Strong computer skills, data entry, Word, Excel, Access, Power Point, and office equipment
  • IDX experience highly desirable
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If you are interested in any of the above positions, please send your resume and salary history to: hr@prospectmedical.com. Also please include the job title in the subject line.

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