Medicare Contracting Controls Policies & Standards Director- Healthcare-Hybrid

This is a hybrid role and will require the ability to work in-person.
Must reside near one of these locations:
Nashville TN, Bloomfield, CT, Austin, TX, Houston, TX or Scottsdale, AZRole SummaryThe Contracting Controls, Policies, & Standards Director is responsible for Medicare contracting governance across all markets.
This role has oversight for provider contracting standards, network policies and related approval oversight activities for Medicare Advantage, including value-based as well as fee-for service programs.
The function protects the integrity of the provider contracting unit cost, structure, and total cost of care savings plans, in turn protecting a large portion of the economic interests for Medicare's P&L.
The role shares responsible for managing Total Medical Costs (TMC) across the regions in conjunction with Market Presidents, with an emphasis on improving Cigna's contract standardization in support of lowering administrative costs and improving service effectiveness.
This individual will be responsible for ensuring all market level contracting strategies and trade-offs are optimized with Cigna's Network Policies and Standards, and will possess a strong understanding of MA growth objectives and corresponding network requirements for all markets.
The Medicare Contracting Standards Lead will also serve as an expert in non-standard contracting tactics/approaches, advising in partnership with the Network Regional Leads on how to achieve the best result for Medicare.Duties & Responsibilities This Leader will have overall accountability in developing and managing Medicare Contract Standards & Policies, in support of Cigna's Network Strategy.
This may include responsibility to approve escalated items where applicable.
This role will have direct management of at least two resources.
Leadership accountability includes:
Serving as the owner of Fee For Service (FFS) reimbursement standards for Medicare, to include standard Provider templates.
Responsible for driving use of structure and terms that have direct contribution to Medicare earnings, in collaboration with the US Medical Network Contracting Governance team.Serving as the owner of value-based reimbursement standards for Medicare.
Inclusive of current contract structure and language assessment, oversight of value-based pipeline, setting process and procedure for financial valuation, and coordination of decision-making for exception management.Supporting the governance process for Fee For Service (FFS) and value-based agreements to ensure contract compliance both against internal policies and CMS regulations to ensure audit readiness, as well as protection of informed and sound financial and operational decisions for Medicare agreements.
Accountable for ensuring smooth flow of communications between the Enterprise, Medicare market, and US Medical contracting teams.Establishing process and long-term management for intake, tracking, assessment and feedback loop of all Medicare contract inquiries.Acting owner of Medicare network policies.
Strategic leader and partner, who will be responsible for aligning matrix partners regarding key decisions on network policy, and related oversight processes to successfully and compliantly enable the business.Establishing and managing Medicare Payment Policy Committee to ensure consistent and compliant interpretation and applications.Leadership influence to the national, US Medical, and local market network teams in the development and execution of strategic and tactical plans to deliver competitive medical networks.Enterprise/Matrix Partnerships:
Partner with leadership from other matrix partners, such as:
Enterprise Operations, Provider Service Operations, Provider Relations, Sales, Medical Economics, Clinical, Affordability Governance & Execution, in developing and implementing a market strategy to support performance and medical cost improvement, and profitable growth.QualificationsMinimum of a Bachelor's degree in business, healthcare, or related field equivalent experience.
Master's and/or MBA degree preferred.Minimum 10+ years in a strategic and leadership role in healthcare network management, including Medicare Advantage networks.
Commercial network experience preferred.
Minimum 8+ years in provider contracting and network development, involving experience with Medicare Fee For Service (FFS) and value-based contracts and methodologies with complex hospital systems, integrated delivery systems, and large physician groups.Ability to be an influential business leader who can impact and garner support from matrix partners across the Enterprise, and operate in a highly matrixed environment.Strong and proven leadership skills including a demonstrated ability to manage required actions in support of delivering on a vision/mission, communicating its purpose, and helping drive outcomes/resultsAdaptable, flexible and able to lead the organization through transformation; proven track record of delivering results that are high quality, profitable and sustainableStrong presentation and facilitation skills with internal and external clients and customers; develop strong working relationships with others, and maintaining them over time.Strong leadership, sponsorship and mentoring talents, identifying the developmental needs of others and coaching to improve their knowledge or skillsIf you will be working at home occasionally or permanently, the internet connection must be obtained through a cable broadband or fiber optic internet service provider with speeds of at least 10Mbps download/5Mbps upload.About Cigna Healthcare Cigna Healthcare, a division of The Cigna Group, is an advocate for better health through every stage of life.
We guide our customers through the health care system, empowering them with the information and insight they need to make the best choices for improving their health and vitality.
Join us in driving growth and improving lives.Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.If you require reasonable accommodation in completing the online application process, please email:
*** for support.
Do not email *** for an update on your application or to provide your resume as you will not receive a response.The Cigna Group has a tobacco-free policy and reserves the right not to hire tobacco/nicotine users in states where that is legally permissible.
Candidates in such states who use tobacco/nicotine will not be considered for employment unless they enter a qualifying smoking cessation program prior to the start of their employment.
These states include:
Alabama, Alaska, Arizona, Arkansas, Delaware, Florida, Georgia, Hawaii, Idaho, Iowa, Kansas, Maryland, Massachusetts, Michigan, Nebraska, Ohio, Pennsylvania, Texas, Utah, Vermont, and Washington State.Job SummaryJob number:
23012447Date posted :
2023-07-19Profession:
OperationsEmployment type:
Full time