Director, Health Plan Provider Contracting

Technical Summary:

The Director, Health Plan Provider Contracting leads the development, negotiation, implementation, and oversight of provider contracts that support the organization's strategic, operational, financial, and regulatory goals. This role manages a team of Contract Managers and Contract Analysts and oversees relationships with hospital health systems, Sub-Acute and ancillary providers.

The Director is responsible for developing provider contracting strategies, negotiating and executing complex agreements, reviewing financial analyses, managing provider disputes, and ensuring contract compliance. Working closely with Operations, Finance, Legal, Compliance, Claims, Marketing, and Executive Leadership, this position serves as a key liaison to align provider partnerships with business objectives.

The role also oversees contract administration, payment integrity, audits, contract configuration, and initiatives focused on managing external medical costs and improving operational efficiency. Through strong leadership, strategic negotiation, and cross-functional collaboration, the Director ensures high-performing provider networks, effective contract outcomes, and the delivery of high-quality, cost-effective healthcare services.

Job Summary:

In addition to the responsibilities listed below, this position is also responsible for driving expectations for the development and/or consultation with the legal team of contract templates and language; championing strong communication techniques when responding to inquiries about contract templates and language; leveraging research on contract rates and services to select best service; setting the direction for the development of rate methodology and strategies; evaluating the network composition against regulatory metrics, health plan client requests, and/or clinical access adequacy needs; driving collaboration efforts with various services lines to develop rate/contract strategies to improve access and availability and service delivery expansion; identifying necessary adjustments to contracting strategy and coordinating operations based on federal and state mandates or regulatory requirements; developing best practices for the negotiation and completion of companion agreements, letters of intent, and/or memoranda of understanding; and developing provider programs in Pay for Performance Agreements, Pay for Quality Agreements, Value Based Purchasing Contracts, and Total Cost of Care.

Essential Responsibilities:

• Prepares individuals for growth opportunities and advancement; builds internal collaborative networks for self and others. Solicits and acts on performance feedback; drives collaboration to set goals and provide open feedback and coaching to foster performance improvement. Demonstrates continuous learning; oversees the recruitment, selection, and development of talent; ensures performance management guidelines and expectations to achieve business needs. Stays up to date with organizational best practices, processes, benchmarks, and industry trends; shares best practices within and across teams. Motivates and empowers teams; maintains a highly skilled and engaged workforce by aligning resource plans with business objectives. Provides guidance when difficult decisions need to be made; creates opportunities for expanded scope of decision making and impact.
• Oversees the operation of multiple units within a department by identifying member and operational needs; ensures the management of work assignment completion; translates business strategy into actionable business requirements; ensures products and/or services meet member requirements and expectations while aligning with organizational strategies. Gains cross-functional support for business plans and priorities; assumes responsibility for decision making; sets standards, measures progress, and fosters resolution of escalated issues. Communicates goals and objectives; analyzes resources, costs, and forecasts and incorporates them into business plans; prioritizes and distributes resources. Removes obstacles that impact performance; guides performance and develops contingency plans accordingly; ensures teams accomplish business objectives.
• Supports continuous improvement efforts by: effectively prioritizing risks and encouraging teams to use data-driven approaches when identifying and/or consulting on continuous improvement opportunities across the contract ecosystem (e.g., identifying business and operational disparities between organizational and provider expectations, constraints, and risks to accessible care; building and maintaining relationships); allocating resources to the department for implementing process improvement initiatives to aid providers and business goals; driving and fostering collaboration with internal and external partners to develop network strategies and implement improved access to care; and may also include providing expert guidance and oversight to the modeling and analysis of provider and market data to drive solutions and strategies for improvement initiatives.
• Ensures contract commitments are met by: evaluating provider operation and management data trends to generate short-term strategies for assessing and improving provider compliance; driving systems to address and resolve complex issues related to provider compliance with contract terms and conditions; implementing systems and strategies to ensure provider compliance with state and federal regulations as well as KP policies and procedures; and reviewing and negotiating complex contracts and consulting with Provider Systems Administration (PSA) or its equivalent as needed to ensure proper contract interpretation and operational readiness and driving corrective actions as identified through contract performance.
• Supports contract strategy development by: driving the implementation of long-term strategies that improve the quality of and access to patient care while managing outside service costs and ensuring the continued growth and success of the department; leveraging market insights and highly advanced knowledge to provide strategic consultation on local service delivery planning and delivery system leadership to aid in the achievement of provider priorities and strategies; driving a collaborative culture across the department to ensure provider strategies meet the unique needs of diverse stakeholders; and identifying gaps, providing feedback, and driving strategies for peer training of new hires and contingent workers(e.g., establishing contract language, determining payment rate parameters, defining workflow and business processes, and ensuring cross-training across all service lines).
• Grows the Provider Network by: driving outreach efforts with potential partners/alliances to create relationships that fill service gaps or decrease costs in current service offerings; developing, maintaining, and managing trusted and strategic partnerships with networks of providers to understand their unique challenges, goals, and future directions; acting as a trusted representative for networks of providers and KP by implementing communication strategies and driving transparency around issues and areas for improvement (e.g., contract compliance such as access, availability, referral operations, and/or supporting member complaints); and supporting provider site visits, daily interactions, and ad hoc meetings by aiding in the creation of objectives for the development of itineraries and agendas, gathering of credentialing materials, and/or initiation of this process.
• Contributes to provider satisfaction by: leveraging advanced knowledge of provider/contract operations to advise the department on the consultation of highly complex issues that arise from contract configuration/interpretation and/or related to claims/disputes, billing, payment, reimbursement, directories, other operational issues, and/or directories; developing innovative solutions to address provider questions and problems more efficiently; and negotiating for the development and delivery of training to aid provider education and orientation on health plan systems, processes, and/or credentialing.