Value Based Contracting Leader - Hybrid

Summary of Job

Responsible for negotiating and managing competitive and complex value-based relationships with EmblemHealth multispecialty groups, FQHCs, IPAs, and hospital provider partners. Develop and utilize internal guidelines, strategic growth opportunities, market research, and financial standards to improve Enterprise value-based network's performance. Working with Finance and Health Care Economics and Analytics teams, build and manage end-to-end financial accounting, reserves, and reconciliations for all value-based contracts. Lead a team of contract specialists to work cross-functionally internally and externally to manage provider relationships, standardize analyses, streamline processes, and manage performance trends to improve overall relationships with new and existing value-based providers. Travel to multiple covered areas within assigned markets in NYS to participate in provider meetings, perform engagement and field activities. Develop and execute special projects, including provider network optimization opportunities to continuously improve unit costs, pricing, value, and competitive market pricing of Enterprise value-based contracts.

Principal Responsibilities

• Identify, design, negotiate, contract, and manage new and existing strategic partners, including both fee-for service and value-based terms on profit sharing, downside risk, and governance requirements as required to bring value to EmblemHealth, members, and providers; responsible for EmblemHealth contracting across the value-based spectrum (P4P, Shared Savings, Shared Risk, Global Risk, Delegated, Bundles/Episodes/Specialty Programs, PPO Models).
• Research federal, state, and competitor strategies on value-based payments to align contract improvements and assure compliance with all regulatory requirements.
• Establish oversight of contract performance through defining and tracking clinical, financial, and quality metrics; maintain accountability for specific initiatives associated with productive value-based contracts.
• Serve as value-based subject matter expert for Government Programs, Legal, and Actuarial reporting on DFS/NYS/DOH regulatory requirements; respond to all routine and ad hoc regulatory reporting and requests for information (RFI/RFP).
• Maintain PADU for value-based provider contracts and ensure team contracts within established parameters.
• Ensure VBP provider contract terms are tracked, loaded, and implemented prospectively in the system.
• Identify deficiencies in individual and aggregate contract performance; develop and implement mitigation strategies, including contracting alternatives and re-negotiation opportunities.
• Work with key stakeholders internally and externally to address provider concerns; develop and execute new workflows to improve internal processes impacting value-based relationships.
• Manage end-to-end financial accounting for all value-based contracts, including capitation, purchase orders, bank accounts, reserves, financial reconciliations, and delegate claims issues.
• Lead contract reconciliations, including capitation payments, incentive payments, and quality performance; inform Finance of financial changes impacting reserves and accruals.
• Ensure maintenance of value-based contracting term databases across organization to support EmblemHealth forecasting and budgeting.
• Lead and develop team members to drive value across multiple provider types and negotiate competitive arrangements. Work on-site as required to effectively engage team members and providers.
• Define team objectives and measure performance to goal.
• Develop and manage team, empowering their success and growth through coaching and development.
• Establish foundational relationships with cross-functional leaders across stakeholder departments to influence roadmaps and support team to advance work.
• Work cross-functionally to develop and execute provider network improvement opportunities and projects, including cost optimization, trend analyses, network simplification, provider incentive programs, and other innovative initiatives to continuously improve unit costs, pricing, value, and competitive market pricing.