Director, VBR & Risk Adjustment

CareSource; Northern (KY); Hybrid; USD 113,000 - 198,000; Full time

Job summary

CareSource in Kentucky seeks a Director, Network Performance & Engagement to lead provider network operations, focusing on value-based contracting, TCOC initiatives, and quality programs. You will guide strategy, analytics, and implementations to improve member outcomes and cost efficiency.

Responsibilities include overseeing contracting, network access, regional business planning, stakeholder engagement, budgeting, and performance improvement initiatives, with travel up to 25%.

Qualifications

• 5+ years in healthcare network management
• 5+ years of leadership/management experience
• Managed Care experience preferred

Responsibilities

• Oversee provider contracting and network relationships to ensure satisfaction
• Lead initiatives to improve quality outcomes and risk adjustment scoring
• Develop regional business plans to expand service area and enrollment
• Monitor budgeting and forecasting to meet financial goals
• Represent CareSource in local markets and industry organizations
• Coordinate policy development and performance improvement efforts

Skills

Value Based Contracting

Regulatory requirements

Financial acumen

Strategic thinking

Leadership

Education

Bachelor's degree in management/healthcare management

Master's degree preferred

Tools

Microsoft Office

Job description

Job Summary

The Director, Network Performance & Engagement provides expert leadership, analysis and ongoing support in the areas of provider network operations including Total Cost of Care (TCOC), value-based purchasing, and state or federal quality initiatives, business issue identification and analysis, business process redesign, application of best practice methodologies, and identification of strategic and financial opportunities / risks.

Essential Functions

• Oversee and monitor physician and standard health partner contracting and on-going relationships with the plan’s physician and health partner network and ensures provider satisfaction is met
• Provide assistance in both the analysis and implementation of initiatives focused on improving quality outcomes and risk adjustment scoring
• Oversee and monitor network access standards for market to include recruitment for network gaps and/or new product development
• Develop regional business plan based on the market business plan that will expand the service area, build the enrollment of the plan, and improve quality outcomes for the network
• Represent CareSource to local market through community engagement and board memberships and play an active role in the local trade and professional organizations
• Monitor the financial activities of the plan including budgeting and forecasting to ensure financial goals are met
• Maintain a strong and cooperative working relationship with provider agencies and regulatory agencies
• Collaborate as a change leader in translating issues, goals and objectives into practical and integrated solutions and services that help to ensure optimum business performance
• Oversee the development and application of policies, standards, benchmarks, metrics and quality controls
• Work in conjunction with staff, consultants, management and administration to design project plans, conduct studies, make recommendations and develop implementation plans for operations improvement that enhance productivity, resource utilization, and/or customer service
• Develop and coordinate the implementation of performance improvement measurement, reporting and feedback systems
• Serve as system administrator for contract management databases; instructs site-specific user administrators, creates profiles for users, and coordinates upgrades with Information Technology
• Secure resources, define roles and responsibilities, set direction, align and coordinate initiatives relating to enhanced operational performance or sustained division goals
• May lead, direct and / or participate in the vendor selection process including identification, evaluation and selection, the development of contracts and agreements, and contract compliance for tools and services related to provider network operations strategic initiatives
• Communicate clearly and professionally with all levels of the organization, from executives to front line staff, demonstrating an executive presence
• Oversee and manage support teams, which includes responsibility for the hiring, supervision, development and evaluation of colleagues
• Prepare periodic written reports and makes presentations to executive leadership summarizing activities, accomplishments and future recommendations
• Maintain a working knowledge of applicable Federal, State and local laws and regulations
• Perform any other job related duties as requested.

Education and Experience

• Bachelor's degree in management, healthcare management or related field required
• Master's degree in business, healthcare management or associated field preferred
• Equivalent years of relevant work experience may be accepted in lieu of required education
• Five (5) years in healthcare network management experience required
• Five (5) years of leadership/management experience required
• Managed Care experience preferred

Competencies, Knowledge and Skills

• Strong knowledge of Value Based Contracting methodologies and operations and/or experience in health care quality
• Advanced proficiency level with Microsoft Office, including Outlook, Word and Excel
• Ability to operate smart phone, iPad, or other mobile communication devices
• Knowledge of provider contracting and familiarity with provider network operations
• Knowledge of regulatory requirements for Marketplace provider network operations
• Excellent oral, written and interpersonal communication skills to effectively interact, exercise discretion, judgment and diplomacy when dealing with internal and external customers
• Strong financial background
• Knowledge of managed care industry, trends, and accreditation, including quality improvement and NCQA provider network requirements
• Ability to work independently and within a team environment
• Attention to detail and work plan creation, implementation, and evaluation
• Business acumen and strategic thinking, yet able to execute tactically
• Demonstrated ability to adjust to shift priorities, multi-task, work under pressure and meet deadlines
• Proven ability to recognize opportunity for improvement and lead change
• Proven track record of leading teams focused on the consumer / member experience that demonstrated empathy and compassion and tracked results
• Proven track record in driving continuous improvement efforts to improve member experience and tracked results

Licensure and Certification

• None

Working Conditions

• General office environment; may be required to sit or stand for extended periods of time
• Up to 25% (regular) travel to attend meetings, trainings, and conferences may be required

$113,000.00 - $197,700.00 CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Salary

Organization Level Competencies- Fostering a Collaborative Workplace Culture- Cultivate Partnerships- Develop Self and Others- Drive Execution- Influence Others- Pursue Personal Excellence- Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.

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