OptumServe provides health services and proven expertise to help federal government agencies tackle some of the biggest challenges in health care. We partner with the Departments of Defense, Health and Human Services, Veterans Affairs and other organizations to modernize the U.S. health system and improve the health and well-being of Americans. You'll help improve the health of millions. And you'll do your life's best work.(sm) Primary Responsibilities:Review government contract requirements in order to determine the impact to beneficiariesGather data from relevant sources in order to respond to stakeholders' requests (e.g., government, e.g. VHA, VBA, CMS, DHA, etc,; internal teams)Analyze network and/or provider performance based on contract requirements along with key indicators (e.g., compliance with regulatory audits; financial performance; Benefit Cost Ratio; risk adjustment scores; prevalence rates; Unit Cost Reduction Trend) in order to determine which programs to implement and/or modifyFamiliarity with government agency (VHA, VBA, DHA, CMS, etc) uses of incentives and disincentives in a contract and effects on businessResearch competitor and external information regarding key network characteristics and contracting strategies in order to develop products and programs for government bidsDevelop reputation for fairness and customer service among providersFamiliarity with state-or-the-art analytics for provider performance to include outcomes, quality, cost/efficiencies, and customer satisfaction Develop incentive programs for providers based on quality outcomes and cost (value-based care)Ensure relevant contract and demographic information is loaded into the applicable platform in order to support analysis and review -Review and analyze member/provider population information (e.g., cultural information; demographics; geographic coverage) in order to determine potential network gaps in care and risk adjustment indicator opportunities and develop mitigation plans to close any gapsImplement new rates with contracted providers based on provider performance (outcomes and costs)Validate network data for programs (e.g., transparency program)Develop metrics and create performance reports for pay-for-performance programs (e.g., PBC; PCPI)Determine performance metrics and programs to apply to specific providers based on competitive data, internal data (e.g., provider improvement opportunities) and applicable government contract and legal and regulatory requirementsProvide guidance to internal stakeholders regarding administration of contracts (e.g., contract language; coding)Identify needs and create infrastructure and parameters for programs / networks / contracts (e.g., contract language; clinical quality initiatives; internal support)Communicate with key stakeholders (e.g., network management contractors) to ensure programs/networks/contracts comply with/coordinate with relevant internal and/or external stakeholders to ensure that programs / networks / contracts are designed and implemented to meet local, regional, and/or national market needsCreate and/or implement communication/training materials (e.g., talking points; FAQs; step action chart; metric evaluation tools) in order to educate affected stakeholders on new programs and/or processesConduct visits with external health care providers to promote risk adjustment score accuracy (e.g., early detection; accurate documentation and coding) and compliance with applicable regulatory guidelines (e.g., VHA and VBA and DHA requirements, CMS; HEDIS/STARS Quality Measures, contract requirements)Work with local, regional, and/or national networks and/or stakeholders in order build support for program/contract implementation standardsUtilize Best Practices for building a high performing network leveraging UnitedHealthcare and Optum networks or leased networks as needed. Development plan for a comprehensive network including a proactive process for recruiting and retaining providers to certify access for veterans and/or Active Duty and families depending on the contract in all areas - both rural and urban. Support innovative use of technology and providing clinical services to improve access to care and reduce health care disparities for individuals in traditionally underserved populationsFamiliar with determining network needs including:Assessing the estimated number of beneficiaries served in each countyUnderstanding the health care services required locally for the unique population in each county and region Complying with access standards and requirements for GeoAccess distance and travel timeUnderstanding the special needs of the targeted veterans/military or unique CMS population, including their cultural, linguistic, racial and ethnic characteristicsAbility to manage gaps in care. Establish best practices for managing both geographical and clinical gaps in care that may exist in product offerings. Develop intake processes to handle gap requests with the goal of directing veterans / military to an appropriate provider within the network and within close proximity to the veteran's / Active Duty's home address Familiar with prescriptive government timelines and recruiting to meet metrics for access and turn-around-times on charting and/or evaluation submission to government. The turn-around-time for these cases can range from 2-15 days based on state / compliance guidelines; however, the UnitedHealthcare best practice is to have case completed in one business day. This process is one way in which UnitedHealthcare deploys best practices to ensure veterans are receiving timely and appropriate careSeek feedback from relevant internal and/or external stakeholders regarding potential program/network improvement opportunities and needsConduct proactive outreach with external stakeholders (e.g., health care providers; health plan) to demonstrate the value of services and offeringsCollaborate with relevant internal and/or external stakeholders to resolve issues and obstacles with network/program/contract performanceCollaborate with the contracting team to ensure adherence to internal contracting standardsCommunicate with applicable stakeholders to provide performance updates regarding program/contract implementation (e.g.,objectives; goals; timelines; schedules; issues; performance against standard contract agreements)Follow-up with stakeholders to ensure issues have been resolved and addressed effectively and timelyManage external relationships with third-party vendors to ensure program SLAs are metDemonstrate understanding of demographic systems (e.g., Emptoris; NDB)Demonstrate understanding of claims issues providers may face. Demonstrate understanding of report generation and workflow management systems (e.g., ChartFinder; InSite; Sharepoint Documentation; Salesforce)Demonstrate understanding of contracting strategies (e.g., facility; ancillary; physician) in order to support field objectives/MBOsDemonstrate understanding of key provider/contract/network performance and/or risk adjustment indicators (e.g., prevalence rate; recapture rates; MWOV; RAF scores)Demonstrate understanding of provider group operations and stakeholder / client business modelsDemonstrate understanding of documentation and coding procedures (e.g., ICD-10)Demonstrate understanding of applicable health care regulations (e.g., HIPAA; ARRA; CMS, TRICARE Manuals, VHA, VBA and CMS requirements)Demonstrate understanding of operations of key business partners (e.g., Clinical Service; Medical Management; Clinical Quality Management, Health Care Economics)Move toward value-based care reimbursement based on quality outcomes and costs in the form of fully at risk, upside incentives, bundled payments, etc. Capable of implementing value-based care pilots as directed by the government
Required Qualifications:BA or BS degree 10 or more years of experience network management / contract management role, such as contracting, provider services, etc.5 or more years of network experience in the DHA, VHA, VBA, CMS or similar government environmentUnderstanding of unique culture and requirements of VA and DOD goals of private networks which may include use of VA or DOD facilities as well as the network and almost always carry measureable access and location requirements5 or more years of experience in program design & compliance with network requirements8 or more years of leadership experience Experience with Network Adequacy Experience with all physician / facility / ancillary contract reimbursement methodologiesExpert level of knowledge of business processes that impact facility / ancillary contract loading and auditing, including the complexities of the contract submission, validation and maintenance processWorking knowledge of provider credentialing and network and credentialing accreditationWorking knowledge of value-based care platforms such as ACOs, Bundled Payments, etc.Location: Open, but prefer: Southern California, Washington, D.C Metro Area, Lacrosse, WI, Eden Prairie, MN, or Tampa, FLSoft Skills:Ability to influence without formal authority Ability to convey complex or technical information in a manner that others can understandDemonstrated ability to make strategic, operational and administrative decisions in response to emerging conditions and environmental circumstancesProven ability to drive, lead and communicate change effectively in a fast-paced environment and be adaptable within the changing environmentAbility to provide recommendations and insight regarding improvements to internal and external processesAbility to manage programs and projects in a strategic and professional mannerAbility to manage and support organizational change and help assist individuals through the transitionStrong ability to communicate effectively and efficiently at multiple levels of large, complex organizations. Must be able be to lead, manage and inspire people at all levels within the organizationSolid organizational, management, administrative and human relations skills, and a style which exhibits emotional maturity, leadership, collaboration and teamworkDemonstrated ability to solve complex business problems and strong analytical skills with ability to drive transformational, consumer - centric change and manage long - term programsStrong history of quickly building relationships, gaining credibility and partnering with business leaders. Must excel at building teams and collaborating across multiple distinct business groups Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make health care work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.(sm) Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment. Job Keywords: network management, contract management provider network, Network Adequacy, Leadership, San Diego, CA, California, Washington, D.C, District of Columbia, La Crosse, WI, Wisconsin, Eden Prairie, MN, Minnesota
Internal Number: 747055
About UnitedHealth Group
Our mission is to help people live healthier lives and to help make the health system work better for everyone.- We seek to enhance the performance of the health system and improve the overall health and well-being of the people we serve and their communities. - We work with health care professionals and other key partners to expand access to quality health care so people get the care they need at an affordable price. - We support the physician/patient relationship and empower people with the information, guidance and tools they need to make personal health choices and decisions.