Company Statement

For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.

Director, Value Based Contracting

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Director and Equivalent
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190EJ Requisition #
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Negotiate competitive and complex contractual relationships with primary care, multi-specialty group, FQHC, IPA and/or hospital providers according to pre-determined internal guidelines and financial standards. Maintain accountability for specific medical cost initiatives with an emphasis on executing productive Value Based Contracts to support the Medicaid and Medicare market expansion efforts. Manage a network management team of Provider Network Operations Managers.  Work cross-functionally to execute network strategies. Lead provider innovation, provider initiatives and network strategy, including network provider pricing/fee schedules and cost optimization, trend analysis and provider network improvement opportunities.  Develop and implement provider network innovation and optimization standards and guidelines to increase market share, revenue growth, and quality outcomes.


Responsibilities:

  • Negotiate competitive and complex contractual relationships with providers according to pre-determined internal guidelines and financial standards. 

  • Maintain accountability for specific medical cost initiatives with an emphasis on executing productive value based provider contracts and relationships to support the Medicaid and Medicare market expansion efforts. 

  • Provide oversight of the development, establishment, implementation, and maintenance of the EmblemHealth value based provider contracts and relationships.

  • Ensure VBP provider contract is loaded and  implemented successful in the system.

  • Research Federal, State and competitor strategies on value-based payments. 

  • Attend conferences and other events to ensure the business is fully aware of value based program efforts on all levels.

  • Establish an EmblemHealth oversight, monitoring and management process to optimize results including defining the underlying metrics of value based programs and value based provider contracts and relationship models.

  • Develop, implement and maintain a multi-year strategic roadmap for the company’s value-based payments strategy.

  • Work with Product and Sales in developing innovative plan design and the Emblem value proposition story.

  • Lead the identification, development, work process design and implementation of new network provider value based contracting models.

  • Research Federal, State and competitor strategies on value-based payments. 

  • Attend conferences and other events to ensure the business is fully aware of value based program efforts on all levels.

  • Identify and contract with a strategic Management Service Organization (MSO) partner, IPA, FQHC, Community or hospital providers.  VBP contract will include profit sharing, down side risk and governance requirements with the VBP provider. 

  • Assess, create, implement and monitor overall performance standards for all VBP contracts. 

  • Ensure MSO/provider initiatives are aligned with EmblemHealth’s overall strategic priorities. 

  • Lead a cross-functional team and work across the health plan to implement targeted initiatives to help providers meet KPIs set forth in the value based agreement.

  • Establish and manage financial, clinical and quality key performance indicators.

  • Monitor and evaluate performance of all value based programs and identify opportunities for improvement or gaps to the VBP’s program’s success.

  • Research and develop appropriate metrics to include in underlying agreement.

  • Identify providers for possible strategic partnership and collaboration who align with our overall corporate goals related to growth, cost and quality.

  • Proactively work with MSO partner and provider relations team to actively build and launch the MSO.

  • Work with key stakeholders to understand and translate external strategies and requirements into internal implementation plans.

  • Plan and facilitate JOCs with VBP providers to ensure proper oversight of contract and address any issues/concerns as well as discuss joint initiatives with the provider.

  • Oversee administration and management of all aspects of MSO relationship on an ongoing basis.

Qualifications:
  • BA Required; Master’s degree preferred (MBA, MPH, MA)
  • 10+ years healthcare provider experience required
  • Network Management and contracting experience required
  • Risk contracting and risk contract management experience – or – significant provider risk-group operations experience required
  • Other provider contracting or health plan financial operations highly desirable preferred
  • Ability to travel up to 50% to meet with Providers and their representatives required

EEOC Statement

We are committed to leveraging the diverse backgrounds, perspectives and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status or any other characteristic protected by law.

Sponsorship Statement

Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.

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