Aetna Director of Network and Clinical Performance in Patterson, California
Req ID: 54239BR
The Director of Network and Clinical Performance will develop, implement, support, and promote health services strategies, tactics, policies, and programs (including utilization management, quality management, network management and clinical coverage and policies) that drive the delivery of quality healthcare to establish competitive business advantage for Sutter Health | Aetna.
Design, develop, contract, maintain and enhance relationships with facilities, physicians and ancillary providers which serve as contractual networks of care for members; foster growth of managed care products; and enhance profitability of SH|A, while working cross functionally to ensure consistency with all contracting strategies and meeting and exceeding accessibility, quality, compliance, and financial goals and cost initiatives.
This is a highly collaborative role which will leverage superior skills and effectiveness at managing relationships across the different business segments and functional areas of the parent companies. The Director of Network and Clinical Performance will report to the CEO of the Joint Venture.
Drive quality healthcare delivery to establish competitive advantage for SH|A (including utilization management, quality management, network management and clinical coverage)
Optimize interaction with providers and internal business partners to facilitate relationships (including claims payment, contracting, etc.)
Partner with network participants to implement member experience improvements
Develop overlay of JV network in core features/functionality. Identify areas to improve integration/member experience and work cross-functionally with Aetna and Sutter Health workgroups/teams to implement
Evaluates, helps formulate, and implements the provider network strategic plans to achieve contracting targets and manage medical costs through effective provider contracting to meet state contract and product requirements. Collaborates with internal partners to assess effectiveness of tactical plan in managing costs.
Uses data analytics to inform and influence population health to drive behavior change and expand Aetna's medical management programs to address specific member conditions across the continuum of care.
Manages contract performance, and drives the development and implementation of value based contract relationships in support of business strategies. Recruits providers as needed to ensure attainment of network expansion and adequacy targets.
May optimize interaction with assigned providers and internal business partners to facilitate relationships and ensure provider needs are met. Ensures resolution of escalated issues related, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.
Accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.
Provider-facing and has fluency in data analytics. Collaborates with local provider systems and influence care management programs. Ability to analyze data (e.g., medical cost trends) and derive insights to provide better care and deliver services more efficiently.
Represents company with high visibility constituents, including customers and community groups. Promotes collaboration with internal partners.
5+ years in a similar network performance role in a healthcare delivery system, ACO experience preferred
Understanding of Value Based Contracting/Accountable Care and how this relates to improving the quality of care for our members through collaboration
Passion and ability to influence and drive better outcomes in healthcare delivery
Demonstrated experience in population health management and managed care
The highest level of education desired for candidates in this position is a Bachelor's degree or equivalent experience.
ADDITIONAL JOB INFORMATION
Aetna is about more than just doing a job. This is our opportunity to re-shape healthcare for America and across the globe. We are developing solutions to improve the quality and affordability of healthcare. What we do will benefit generations to come.
We care about each other, our customers and our communities. We are inspired to make a difference, and we are committed to integrity and excellence.
Together we will empower people to live healthier lives.
Aetna is an equal opportunity & affirmative action employer. All qualified applicants will receive consideration for employment regardless of personal characteristics or status. We take affirmative action to recruit, select and develop women, people of color, veterans and individuals with disabilities.
We are a company built on excellence. We have a culture that values growth, achievement and diversity and a workplace where your voice can be heard.
Benefit eligibility may vary by position. Click here to review the benefits associated with this position.
Aetna takes our candidates's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.
Job Function: Health Care
Aetna is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veterans status.