VP - Provider Contracting and Network Operations

About Presbyterian Healthcare Services

Founded in New Mexico in 1908, Presbyterian Healthcare Services (PHS) is a locally owned, not-for-profit healthcare system of nine hospitals, a medical group and a health plan. 

 

Presbyterian's health system serves more than one in three New Mexico residents in our clinics, hospitals and as members of our health plan.

 

Our health plan serves more than 600,000 members statewide and offers Medicare Advantage, Medicaid and Commercial health plans.

 

About this Leadership Role

The VP of Provider Contracting and Network Operations has accountability for all aspects of provider contracting, network operations, and provider services. The VP develops strategic partnerships with key providers, providing best in class engagement and driving optimal performance in quality, financials, risk adjustment, utilization management, financial performance, and membership retention and growth. You lead provider network and provider contracting strategies to ensure a robust provider network that meets the needs of our membership, in addition to regulatory requirements. This leader serves as a subject-matter-expert on value-based contracting, standard and advanced provider payment models, and emerging provider payment models and is accountable for provider contract performance and financial outcomes.

• Bachelors degree or equivalent experience in Business Administration, Healthcare Administration or related field.
• Masters Degree Preferred.
• 15+ years of combined experience in managed care, provider contracting, provider network operations and management, and health plan operations experience.
• Knowledge of New Mexico market preferred. 
• Must reside in New Mexico. 
  
  

• Establish the departments strategic vision, objectives, and initiatives in support and alignment with the health plans strategy and priorities, with consistent strategic updates regarding current and future impacts.
• Establish end-to-end provider contracting processes, policies and procedures, effective controls, and operational measures and reporting.
• Accountable for provider contract conformance and performance audits and analysis, in partnership with medical economics, claims operations, payment integrity leadership, and internal audit.
• Serves as the senior negotiator for the provider contracting and primary signatory for all provider contracts, with the CFO as the final signatory.
• Contribute as a key member of the health plan leadership team and key committees addressing the strategic goals of the department, health plan, and enterprise.
• Monitor and assess network adequacy and ensure compliance with federal and state regulatory requirements to meet provider access and availability standards.
• Perform periodic analyses of the provider network from a cost, coverage, and growth perspective and provide leadership in evaluating opportunities to expand or change the network to meet health plan goals.
• Oversee the development of provider networks across expansion markets by leading provider contract analysis related to due diligence.
• Stay current on industry trends, regulatory changes, and emerging models of care delivery to inform and adapt network strategies accordingly.
• Review network reimbursement issues, trends, and root cause analysis and executing on strategies to reduce claims payment discrepancies.
• Manage budgeting and forecasting initiatives for product lines to networks costs and provider contracts, in partnership with Finance and product leadership.
• Oversee analysis of claim trend data and/or market information to derive conclusions to support contract negotiations and ensure strategic focus is on target with overall health plan strategy.
• Seek continuous improvement and optimization of operational efficiency, with automated and industry-leading and integrated technology solutions.
• Foster a culture of high performance, individual and team development, accountability, collaboration, high quality standards, and continuous improvement.
• Accountable for the operations budget and financial performance of Provider Contracting and Network Operations.
• Oversee the company Provider Data Management and accuracy strategy, including the resolution of discrepancies resulting in a more accurate directory.
• Improve the overall provider experience by soliciting feedback in the annual provider survey and acting on areas for improvement.
• Ensure quick and complete resolution of issues relating to reimbursement, directory information, credentialing, and the overall member experience.
• Ensure a seamless and timely credentialing/re-credentialing processes.
  
  

We offer more than the standard benefits!

Presbyterian employees gain access to a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more!

Learn more about our employee benefits:

https://www.phs.org/careers/why-work-with-us/benefits

Why work at Presbyterian?

As an organization, we are committed to improving the health of our communities. From hosting growers' markets to partnering with local communities, Presbyterian is taking active steps to improve the health of New Mexicans. For our employees, we offer a robust wellness program, including free access to our on-site and community-based gyms, nutrition coaching and classes, wellness challenges and more.

Presbyterian's story is really the story of the remarkable people who choose to work here. The hard work of our physicians, nurses, employees, board members and volunteers grew Presbyterian from a tiny tuberculosis sanatorium to a statewide healthcare system that serves more than 875,000 New Mexicans.

About Our Regional Delivery System

Presbyterian's Regional Delivery System is a network of six hospitals and medical centers throughout rural New Mexico including locations in Clovis, Espanola, Ruidoso, Santa Fe, Socorro and Tucumcari. Our regional facilities are home to more than 1,600 clinical and non-clinical employees who help make Presbyterian the state's largest private employer with nearly 14,000 statewide employees. With a variety of services ranging from general surgery to pediatrics to heart and cancer care, our regional employees are proud to provide close-to-home care for their communities.

We are part of New Mexico's history - and committed to its future. That is why we will continue to work just as hard and care just as deeply to serve New Mexico for years to come.

About New Mexico

New Mexico continues to grow steadily in population and features a low cost-of living.

Varied landscapes bring filmmakers here from around the world to capture a slice of the natural beauty New Mexicans enjoy every day. Our landscapes are as diverse as our culture - from mountains, forests, canyons, and lakes, to caverns, hot springs and sand dunes.

New Mexico offers endless recreational opportunities to explore and enjoy an active lifestyle. Venture off the beaten path, challenge your body in the elements, or open yourself up to the expansive sky. From hiking, golfing and biking to skiing, snowboarding and boating, it's all available among our beautiful wonders of the west.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $136.68/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.