Job Description

Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:

• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women

• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR

• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.

• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.

Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.

Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.

Skills / Requirements

JOB SUMMARY

The Sr. Director provides strategic leadership in the development, direction, execution, and evaluation of an effective contracting program. The Director is responsible for assuring the program supports the delivery of quality providers appropriately and effectively, and that meets all contractual and regulatory requirements. This position develops and maintains a robust provider network that meets state-defined accessibility standards and incorporates continuous quality improvement and effective outreach programming. In addition, the Director develops systems to ensure effective coordination between network providers and contracting and ensures the analysis of utilization and cost data is translated to program implementation. Assures that network and contracting function are aligned with organizational strategic objectives and financial targets.

JOB SPECIFICATIONS AND CORE COMPETENCIES

  • Strategic Planning:
  • Assists the Network VP in the development of network strategies and innovative reimbursement and risk models to align provider incentives around performance.
  • Negotiates and/or oversees the negotiation of hospital, physician and ancillary provider contracts that allow achievement of company financial performance targets through existing and innovative compensation methodologies.
  • Ensures the network composition includes an appropriate distribution of provider specialties to achieve network adequacy requirements- Responsible for the network adequacy for all CHC products.
  • Monitors and reports significant developments occurring within the provider community and assists in developing a strategic plan to mitigate risks and capitalize on opportunities.
  • Establishes and updates as needed CHC provider contracting policies and procedures and CHC provider contractual materials.
  • Ensures prospective providers are effectively informed and updated as necessary.
  • Monitors the financial performance of the contractual arrangements.
  • Departmental Management:
  • Assists in the development of annual departmental budgets and monitors expenditures to meet administrative cost targets.
  • Ensures all related operations, communications, contract documents and daily interactions with providers remain compliant with regulatory and accreditation standards.
  • Ensures timely and accurate submission of related regulatory and compliance reports associated with the Network Contracting.
  • Monitors compliance with contracting standards, reimbursement methodologies and the application of model contract language.
  • Works closely with Configuration and Provider Data to oversee contract set-up and configuration to ensure accurate claims adjudication.

Cross-functional Duties:

  • Works with the Finance analytics team, Medical Management workgroup, and Executive Team as needed to make essential data-driven decisions.
  • Actively contributes to achievement of departmental goals, as identified in Departments annual business plan, including specific departmental process improvement plan, and other duties as assigned.

QUALIFICATIONS:

  • Education/Specialized Training/Licensure: BA/BS; 4 years equivalent work experience may substitute for degree requirement.
  • Work Experience (Years and Area): 7 years in healthcare, with at least 5 years experience in Providers/Managed Care Contracting. Medical contract negotiations experience with BA/BS degree.
  • Health Plan experience, Experience within the Houston market.
  • 11 years in healthcare, with at least 5 years expereince in Providers/Managed Care Contracting. Medical contract without BA/BS degree. 
  • Management Experience (Years and Area): 4 years direct supervision experience required.
  • Software Proficiencies: Microsoft Office Suite
  • Other: Must have car and valid Texas Drivers license Contracting experience with hospital and physician practice (group practice & solo practitioner) required. Developing and implementing strategic objectives for the contracting function. Experience implementing provider incentive programs and pay-for-quality programs, claims payment and CRM systems. Demonstrated ability to manage and develop staff in medical contract negotiation.
  • Experience with QNXT and Salesforce.

Application Instructions

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