Provides leadership, guidance and oversight for a team of Network Managers, Contract Negotiators and Contract Consultants to ensure overall network competitiveness, service and profitability for given market or geographical area. Oversees all provider contracting functions, strategic relationships, plan management, and the value based contracting strategy for growth. The role will integrate provider network plans, activities, programs, policies and initiatives in order to effectively manage medical benefit costs while continually improving quality, access and customer satisfaction. Works cross-functionally to establish and execute network strategies.
Builds and manages a high functioning team responsible for ensuring overall network competitiveness and profitability for given market or geographical area. Role may have responsibility for one or more markets, depending on business structure and required complexities. 66564
Leads and helps to develop the overall network strategy for given area of responsibility (ie. defined geographic area) and drives teams to execution.
Leads the design, development, management, and/or implementation of strategic network configurations that drive membership growth.
Develops, directs and maintains relationships with external and internal care providers and their organizations.
Provides network strategy support to sales and marketing, along with assistance on community relations related items to achieve market and segment goals.
Oversees and/or negotiates the most complex, competitive contractual relationships with providers according to prescribed guidelines in support of enterprise and local strategies.
Overall accountability for contract negotiations involving all provider types including at-risk arrangements, IPA/PHO, hospital and large provider groups.
Provides a solid understanding and expertise in the End-to End aspects of provider contracting from modeling, configuration, utilization management, claims and analytics, including provider risk sharing.
Negotiate complex contract language and initiate legal reviews as needed; ensure all required reviews completed by appropriate functional areas.
Ensures network adequacy and implements actions to build out network expansion markets and/or to close gaps.
Advance the company strategy to adopt value based payment models; Coordinates with VBC network team and/or may directly lead teams to develop, negotiate and manage complex Value Based and Accountable Care (ACO) relationships.
May oversee the negotiation, implementation and management of VBC agreements.
Represents the organization at related external provider meetings and conferences.
May have responsibilities related to Joint Venture alliances.
Works closely with Population Health resources to enable and improve clinical outcomes.
Responsible for understanding medical cost issues and medical cost ratios (MLRs) and initiating appropriate action to manage improvement initiatives and scoreable action items.
Reviews analytics with medical economics and works with providers to develop collaborative initiatives that improve quality results, manage costs.
Preferred 10 or more years’ experience in managed care; leading and managing teams.
Comprehensive understanding of hospital and physician financial issues and how to leverage technology to achieve quality and cost improvements for both payers and providers.
In depth knowledge of various reimbursement structures and payment methodologies for both hospitals and physicians.
Comprehensive understanding of value based strategies and population health management, and Aetna’s related strategic initiatives.
Strong experience building and maintaining relationships with large hospitals/provider systems, integrated delivery systems and large physician groups.
May require knowledge of MACRA and other government programs (ex. Bundled payments) depending on market.
Solid leadership skills including staff development.
Understands the regulatory environment and ensures contractual compliance with federal and state requirements.
Bachelor's degree or equivalent work experience MBA/Master’s degree preferred.
Additional Job Information:
Job description may also be used for other products besides Commercial medical: e.g., dental, worker’s comp, behavioral health, Medicare, Medicaid, etc.; systems and tools mentioned in the description would align and reflect appropriate product, segment.
General Business - Demonstrating Business and Industry Acumen, Leadership - Anticipating and Innovating, Leadership - Developing and Executing Strategy, Leadership - Driving Change
General Business - Maximizing Work Practices, General Business - Turning Data into Information, Leadership - Collaborating for Results, Leadership - Engaging and Developing People, Leadership - Fostering a Global Perspective
Network Management - Contract negotiation
Desktop Tool - TE Microsoft Excel
Potential Telework Position:
Percent of Travel Required:
10 - 25%
Aetna is an Equal Opportunity, Affirmative Action Employer
Benefit eligibility may vary by position.
Candidate Privacy Information:
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