CommonSpirit Health was formed by the alignment of Catholic Health Initiatives (CHI) and Dignity Health. With more than 700 care sites across the U.S. from clinics and hospitals to home-based care and virtual care services CommonSpirit is accessible to nearly one out of every four U.S. residents. Our world needs compassion like never before. Our communities need caring and our families need protection. With our combined resources CommonSpirit is committed to building healthy communities advocating for those who are poor and vulnerable and innovating how and where healing can happen both inside our hospitals and out in the community.
Responsibilities
This is a remote position, but we strongly prefer someone with West Coast Payer negotiation experience.
Have proven experience negotiating with large payers and full life cylce experience negotiating hospital/physician and ancillary agreements. Must have all three.
Must have capitation experience and knowledge.
Key position that assists with planning, directing, and implementing the managed care goals and objectives related to contract language and reimbursement, negotiation strategy, and National payer relationship management. This position will focus on at least one dedicated National Payer relationship, for which the System Director will negotiate a wide-variety of fee-for-service, capitated and value-based contracts across CommonSpirit Health’s geographies for their numerous business lines (e.g. commercial, government, and service-line specific). The System Director, collects and communicates insight and strategic knowledge to/from the PSR Regional teams, the PSR Growth & Innovation team, and other key departments across the enterprise (finance, strategy, population health, etc.). This position is essential to CommonSpirit Health’s financial performance, having significant impact on the long-term strategic trajectory of the organization. High expectations exist to secure optimal fee for service and value-based reimbursement, protect the interests of the owned and/or affiliated hospitals/ancillaries/professional provider entities in contract negotiations, and strengthen CommonSpirit Health’s relationships with National Payers.
Essential Responsibilities
1. Leads in the development of National Payer strategy, relationships, and contracts with assigned National Payers to further drive a clear and effective negotiation strategy, reimbursement structure, contract renewal planning process, and contract implementation in order to achieve the budgeted and forecasted performance and growth requirements as set forth by National and Regional senior leaders.
2. Gathers information and drafts negotiation goal alignment with Regional senior ministry leaders relative to the strategic, operational, and financial needs and expectations of each Region impacted by the National Payer. Establishes, builds, and maintains positive, strategic interactions and relationships with assigned National Payer(s), employers, providers, and leaders across the ministry.
3. Documents ‘Lessons Learned’ session following each renewal with their assigned National Payer with the PSR and PAE teams involved in the negotiations to document successes as well as opportunities for improvement for future renewals.
4. Engages consistently in effective communication with internal stakeholders across the ministry to ensure key contract terms and requirements are successfully implemented to ensure optimal contract performance and revenue
expectations. Develops and executes communication plans to internal and external stakeholders related to payer relationships, negotiations, organizational contractual obligations, and developments in the managed care marketplace.
5. Works intimately with internal analytics teams. Analyzes and monitors financial aspects of existing managed care contracts and rate structure opportunities. Gathers feedback from ministry leaders on financial, revenue cycle, and
operational issues with the National Payer related to contract renewals, renegotiations, payer compliance, or termination scenarios, and leverages this feedback to make recommendations regarding participation or nonparticipation with new or existing agreements and networks.
6. Makes independent decisions and/or exercises sound judgment based upon appropriate information and objectives. Comprehends and maintains highly detailed information. Accepts and carries out responsibility for direction, control,
and planning.
7. Leads and organizes the dispute resolution process with their assigned National Payer when issues materiality exceed $1M.
8. Leads and organizes sub-projects necessary to support the National Payer negotiation; keeps detailed work plans, and actively tracks the status of open items, following up consistently to ensure deadlines are achieved. Stays current with emerging payer trends, new reimbursement methodologies, regulatory issues, plan benefits, payer activity, products and delivery channels including health insurance exchanges and market competition.
9. Participates in establishing the composition, pricing, and management of fee and value-based payment and risk arrangements with National Payers in support of CommonSpirit Health’s Healthier Communities strategy. Develops,
implements, and maintains value-based payment and risk arrangements in conjunction with national standards & guidelines. Supports the strategic objectives of CommonSpirit Health’s IDNs, population health, and care management
initiatives through directly engaging National Payers and employer customers, including CSH employee health benefits.
10. Participates in and contributes to CommonSpirit Health’s PSR knowledge base through sharing best practices, developing contract performance goals, key metrics, network development, reimbursement and language guidelines, revenue realization, and other applicable work streams.
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Qualifications
Education and Experience
Bachelor’s Degree – equivalent education and experience in payer strategy, managed care or provider network senior level role may be considered in lieu of degree.Minimum of seven (7) years’ progressive leadership experience in the healthcare environment, of which five (5) years are in managed care contracting for a hospital, healthcare system, or health plans in an intensive managed care market.Ability to:
Commercial health Establish, build, and maintain positive, strategic interactions and relationships with leaders across the ministry as well as with external and internal PSR relationships, providers and departments.Identify opportunities and take action to build relationships between one’s area and other areas, teams, departments, or organizations to help achieve business goals.Drafts proposal letters, recommendations, payer outlines, presentations and offers suggestions and ideas to move the negotiations forward.Team leadership and/or supervisory experience in healthcare or financial setting.Creatively problem solve, and to achieve the operational and financial goals of both PSR and the broader organization.Provide feedback on and understand regulations and communicating proactively regarding regulations.