Sr. Director, Provider Network Negotiations… at Optum · Cypress

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health optimization on a global scale. Join us to start Caring. Connecting. Growing together.

Manage the team of contract negotiators for the provider network (physicians, pharmacies, ancillary groups & facilities, etc.) yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management and produces an affordable and predictable product for customers and business partners. Evaluates and negotiates contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls. Establishes and maintains solid business relationships with Physician, Pharmacy, or Ancillary providers, and ensures the network composition includes an appropriate distribution of provider specialties. Monitor contract performance and address non-compliance with any providers with the providers. Provide support to regional medical directors by identifying trends in utilization and new technology or coding that would have an impact to business.

Primary Responsibilities:

• Provide leadership to and be accountable for the performance of managers and/or senior level professional staff within the Optum CA service area
• Lead the detailed design of the Contract Negotiations Lane as part of the broader organization redesign of the Network Contracting department.
• Develop functional, market level, and/or site strategy, plans, production and/or organizational priorities to support the goals and objectives of the regional markets
• Identify and resolve technical, operational, and organizational problems outside own team
• Demonstrate understanding of applicable products for different lines of business (e.g., Employer and Individual; Medicare and Retirement; Community and State)
• Analyze UCRT associated with products, markets, and/or providers to assess performance against budget
• Evaluate current contract performance to identify potential remediation opportunities and/or cost savings
• Demonstrate understanding of and utilize applicable financial tools (e.g., HPM; PPM; FAT; HCE's RVU/Unit tool) and reports (e.g., internal financial models; external reports) to evaluate performance of current contracts
• Demonstrate understanding of contract language to assess financial and operational impact and legal implications of requested contract changes
• Demonstrate understanding of competitor landscape within the market (e.g., rates; market share; products; provider networks; market intelligence; GeoAccess)
• Seek information from relevant sources (e.g., COB data; publications; government agencies; providers; trade associations) to understand market intelligence information
• Balance financial and operational impact of contracts to providers, members, UHN, and different customer groups when developing and/or negotiating contract terms
• Weigh financial and operational information to evaluate continued provider participation
• Interact and consult with Network Pricing team to evaluate different financial arrangements and to identify and recommend applicable payment methodologies (e.g., FFS; Case Rate; Sub-capitation; Pay for Performance) in order to maximize value for stakeholders
• Demonstrate understanding of and utilize applicable financial tools (e.g., HPM; PPM; FAT; HCE's RVU/Unit tool) and reports (e.g., internal financial models; external reports) to develop rates
• Demonstrate understanding of contract policies to ensure compliance and consistent contracting across the enterprise
• Demonstrate understanding of contract language and terms of agreement in order to ensure that financial/operational impact and legal implications are aligned with business objectives
• Utilize appropriate contract management systems (e.g., Emptoris; PEGA; Contract Attachment Repository) to author and execute contracts and to access supplemental contractual documents
• Demonstrate understanding of submission tools (e.g., Delegation Authority Grids; loading grids; Navigator; BPM) to ensure accurate and timely contract configuration for customer groups
• Demonstrate understanding of contractual financial and non-financial terms
• Evaluate market rates and provider performance (e.g., billing patterns; referral patterns; quality and effectiveness) in order to establish provider rates and negotiation strategies
• Communicate proposed contractual terms with provider and negotiate mutually acceptable agreement
• Explain the organization's direction and strategy to internal partners and providers in order to justify methodologies, processes, policies, and procedures
• Demonstrate benefits of applicable reimbursement methodology to internal partners and providers
• Identify and gather information regarding provider issues in order to develop and/or implement strategy to resolve matter, keep manager informed of progress, or escalate issue to appropriate internal business partner
• Report back information from provider meetings to applicable stakeholder (e.g., manager; business partner) in order to determine appropriate action
• Monitor and/or oversee provider financial performance to identify opportunities to improve performance and/or provider relationship
• Communicate contractual and/or operational performance to providers to ensure compliance with contractual terms and protocols
• Demonstrate understanding of provider termination process -Educate providers on the organization's processes, policies, and procedures in order to ensure provider compliance and ease of administration
• Implement local, regional, and/or national initiatives and directives (e.g., ICD10; medical necessity language) through contracting strategies and communication efforts
• Manage UCRT associated with products, markets, and/or providers to identify potential market strategies
• Identify and share best practices (e.g., payment methodologies; negotiation tactics) with national and regional colleagues -Modify and/or develop new payment methodologies in order to execute market strategies
• Present and discuss industry and market trends with internal and/or external groups (e.g., customer groups; brokers; professional associations; providers) in order to facilitate market strategy development and implementation
• Monitor and/or oversee network performance and industry trends to identify opportunities to refine, develop, and/or implement market strategies
• Represent department in internal meetings (e.g., medical management; M&R; C&S) to gather relevant information, present/recommend solutions, and provide updates on results/decision/activities
• Develop and/or implement contracting strategies to support new benefits designs and plans

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 5 years of solid experience in the following areas:
  • Contract Negotiations in Managed Care Environment
  • Management experience in a matrixed environment
• 5 years of solid experience in the following areas:
  • Provider reimbursement types - Capitation, Fee for Service, Per Diem, DRG, Case Rates, ASP, AWP
  • Negotiation of capitation and fee for services provider contracts
  • Strategic Business Planning and Implementation experience at a senior level
  • Management of Direct Reports, plus workflow of indirect team members
• 3 years Network Development Experience (Provider contracting and recruitment)
• Experience presenting to executive and external audiences
• Intermediate level of proficiency in MS Office (Excel and PowerPoint), SharePoint, and customer management software
• Demonstrated excellent Customer Care
• Ability to travel onsite 2x a week in the Southern California office

Preferred Qualifications:

• Profit/Loss Statement Management experience
• Broad-based background in health care and medical management
• Demonstrated excellent oral and written communication skills for both internal and external consumption are a prerequisite
• Demonstrated ability to work effectively with all levels of employees, management, and stakeholders

Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. In addition to your salary, we offer benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with us, you’ll find a far-reaching choice of benefits and incentives. The salary for this role will range from $134,600 - $230,800 annually based on full-time employment. We comply with all minimum wage laws as applicable.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission.

UnitedHealth Group is an Equal Employment Opportunity employer under applicable law and qualified applicants will receive consideration for employment without regard to race, national origin, religion, age, color, sex, sexual orientation, gender identity, disability, or protected veteran status, or any other characteristic protected by local, state, or federal laws, rules, or regulations.

UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.