Director, Value Based Performance

Position Description:

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

This position will lead all aspects of Capital’s network contracting activities related to value-based reimbursement methodologies for the network portfolio, including facility and professional providers. Responsible for direct oversight, management, and training of the contracting staff reporting to this position. Responsible for the negotiation of contract terms, program features, and implementation of strategic network-inspired program designs. Leads the transformation of Capital’s existing network from a primarily fee-for-service driven model to a model of value-based programs that align with the Triple Aim objectives (satisfaction, quality, and cost). The individual will manage and oversee complex projects related to provider networks, reimbursement methodologies, program performance management/governance, and the contractual/statutory/regulatory requirements necessary to ensure compliance with such items as network adequacy etc. Must be able to assess budgeting and forecasting initiatives for inclusion of Value Based provider contracts. Oversees analysis of claim trend data and/or market information to drive conclusions to support program performance and contract negotiations. Leads all value-based program governance activities and builds a culture of cross-functional expertise to empower stronger relationships and performance outcomes. Additionally, this individual will have the ability to represent the Senior Director and/or Vice President in work groups and in communicating departmental, provider partner, and other needs as identified

Responsibilities and Qualifications:

Demonstrate and provide leadership capabilities to develop and deploy complex contracting activities through multiple reimbursement methodologies and to meet overall company objectives. Maintains a positive relationship with all external stakeholders to ensure key contracting objectives can be met. Negotiates all key terms of VBC contractual arrangements within key timeframes required to maintain contractual relationship. Works with Senior Director to create long-term strategic plans and execute new program priorities.

Lead, manage, and oversee contracting staff assigned to the position with the intent to develop skillsets and knowledge to assist in delivering accurate, timely and judicious contract terms. Teaches and trains teams in all aspects of value-based programs to create independence in assessment and the creation of contract/program recommendations.

Demonstrate and provide leadership capabilities in the transition and growth of value-based contracting strategies to support corporate goals and objectives. Lead the development and implementation of “best practice” alternate payment models. Closely monitor CMS’ developments and regulations on healthcare reform to evaluate and incorporate align strategies related to MACRA. Incorporates strategies to align performance-based incentive models between facility and professional contracts.

Lead, manages, and oversees complex special projects effecting network and providers such as, reimbursement policies, mass contracting efforts, and vendor strategies that support multiple cross-functional goals and objectives.

Develop medical costs savings strategies designed to improve plan performance - financially, clinically, and member/provider satisfactions. Serves as a liaison for multiple internal workgroups tied to care costs and corporate quality goals. Assists department head in the implementation of strategies and conducts market and provider intelligence gathering.

Oversight of performance analysis, and clinical/financial opportunity identification for providers in value programs. Responsible for communicating analytical and modeling requirements to internal departments. Partners with internal clinical teams to define and communicate corporate goals in the context of value program components Develops forecasting and budget anticipations related to contractual agreements and monitors actual to budget variances throughout the year.

Skills:

Must be able to lead and motivate individuals and organization within an ever-changing environment. Demonstrated character, competence, and courage to have the social influence in which they can enlist the aid and support of others in the accomplishment of departmental and corporate objectives. Builds and maintains valuable business relationships that support influencing without authority and driving toward common goals.

Strong analytic and conceptual skills to develop new analytic and financial models. Advanced decision making, problem solving, and customer presentation skills (verbal and written). Proven ability to analyze complex problems and issues, determine impact, and develop business solutions or recommendations for changes.

Expertise to mentor and develop team members toward empowerment and self-sufficiency in considering value program features within the context of larger participation agreements.

Exceptional relationship building talent to create productive partnerships internally and externally. Must have the flexibility and perception to quickly adapt to different communication styles and approaches, with the skill and gravitas to respectfully challenge differing viewpoints. Executive presence and the ability to conduct crucial conversations are both necessary for success.

Deep knowledge and experience with all facets of alternative payment model/value-based programs including the various levers available to align incentives. Must have a thorough understanding of how value-based programs and fee-for-service reimbursements impact each other, as well as the interplay with areas such as HEDIS quality and risk adjustment.

Ability to quickly gain knowledge of new business processes and issues.

Knowledge:

Knowledge of current and emerging reimbursement and alternate payment models, to include governmental reimbursement methodologies.

Advanced understanding of contractual language and necessary provisions to support corporate goals for financial and clinical outcomes.

Knowledgeable of various State and Federal licensing requirements and bodies; and existing accreditation organizations (Joint Commission, CARF etc.).

Experience:

A minimum of eight years of successful management experience in a health care related business, with a minimum of 3 years negotiating provider agreements.

3 or more years’ contractual and/or operational experience with VBC programs (ACO, PCMH, and bundled payments) required, including the governance structures to monitor and drive program performance.

Project Management and/or program implementation experience highly preferred.

Education and Certifications:

Minimum requirements include a Bachelor’s Degree in a health related field or 8 plus years directly related healthcare industry experience in lieu of Bachelor’s degree. Master’s degree and/or Six Sigma certification valuable.

About Us:

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community. We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.

And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.

Permanent