Jamaica Plain, Massachusetts
Wilkes-Barre, Pennsylvania
Indianapolis, Indiana
Beaumont, Texas
Papillion, Nebraska
Russellville, Arkansas
Posted: 01-Oct-25
Location: Dallas, Texas
Internal Number: 25015179
About Us
Here at Baylor Scott & White Health we promote the well-being of all individuals, families, and communities. Baylor Scott and White is the largest not-for-profit healthcare system in Texas that empowers you to live well.
Our Core Values are:
- We serve faithfully by doing what's right with a joyful heart.
- We never settle by constantly striving for better.
- We are in it together by supporting one another and those we serve.
- We make an impact by taking initiative and delivering exceptional experience.
Benefits
Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include:
- Immediate eligibility for health and welfare benefits
- 401 (k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level
Job Summary
The VP Coverage Network is responsible for planning, developing, growing a high-quality and efficient provider network that anchors all Coverage products (Baylor Scott & White Health Plan, BSWHP, and Baylor Scott & White Quality Alliance, QA) of Baylor Scott and White Health (BSWH). This will include strategic and operational oversight of the provider network strategy and development, provider contracting, network operations (which includes credentialing and provider data management), and provider relations and provider performance.
The leader is responsible for setting the network strategy and ensuring a high-value core network of employed and independent providers. Beyond curating the core network, the leader oversees all aspects of the Health Plan provider network development, including provider research and network adequacy assessments, policy development, contract development, provider solicitation, and health system-aligned expansion of the provider network including physicians, hospitals, allied health providers, other ancillary providers.
The leader directs and monitors network performance (including quality, utilization, network retention "keepage", and total cost of care performance), and the leader?s team along with collaborators from other Coverage teams, facilitates provider relationships, orientation and education, issue resolution, and performance optimization as it relates to employed and independent providers of both the Quality Alliance network and the Health Plan networks. The VP develops relationships with internal and external independent providers - including physicians, hospitals, allied health professionals, post-acute and ancillary providers - as well as administrators, healthcare delivery system leaders, and other stakeholders to strengthen and grow the networks. . In addition, the leader directly facilitates and support pricing and repricing activities for various third-party administrator (TPA) platforms. The leader will collaborate regularly with Health Plan operations on network configuration, provider data and audit function (the provider data integrity unit).
This position could be based out of Dallas or Temple, Texas.
Essential Functions
- With executive leadership and other collaborators throughout the Coverage system and healthcare delivery system, sets the network strategy for the Coverage business unit.
- Oversees the network development of the coverage system.
- Develops and implements network development plans and priorities that align customers and stakeholders in accordance with overall business strategy and objectives of BSWH.
- Develops relationship models that address critical success factors for the organization across various practice types, such as employed, independent, and hospital-based practices as well as post-acute providers.
- Oversees the successful formulation, development, and implementation of reimbursement arrangements that align the healthcare delivery system with quality, outcome, and expense objectives.
- Leads operational aspects of network development and contracting, including information gathering, negotiation, implementation, and reporting through provider relations and network management activities.
- Ensures that all contracts comply with the operational, quality, and legal requirements; and modifies contracts as business needs and membership targets are achieved
- Leads the implementation and negotiation of provider contracts of all network providers.
- Ensures contract processes, policies, and workflows are optimally designed to maximize efficiencies and reflect industry best practices.
- Leads the development and implementation of an audit program that resolves issues and errors and adjusts to developing market conditions.
- Oversees the network development contract audit processes to ensure consistency between contract terms and adjudication of authorizations and claims.
- Plays a critical role in overseeing pricing and repricing exercises to support TPAs other than that of BSW Health Plan TPA and in support of the enterprise Direct to Employer (DTE)/Employer Solutions strategy
- Partners closely with the health plan operations Provider Data Integrity Unit (pricing, configuration, provider data and audit) to ensure the accuracy and completeness of provider set up and implementation.
- Owns and facilitates all provider relations (and partners with the physician and Clinical Excellence teams) for all quality, utilization, and total cost of care reporting and performance optimization. With finance partnership, oversees and communicates the annual distribution model to health system leaders, medical group leadership and independent providers.
- Investigates, remediates, tracks and informs processes to reduce provider escalations initially triaged by Health Plan or QA contact centers or other intake means.
Key Success Factors
- Bachelor's degree in business, healthcare administration, or related field preferred; Master's degree preferred
- 10+ years of experience in healthcare leadership
- Must have network experience with both a health insurance plan (payer) and a health system (provider). Strongly prefer a candidate with experience in clinically integrated networks and/or accountable care organizations
- Able to effectively navigate ambiguity, lead through change and bring others along
- Strong understanding of the financial and strategic impact of provider contracts and network
- affiliations in a health care delivery marketplace; Experienced with alternative payment models is highly desired
- Excellent financial analysis skills.
- Strong collaboration and negotiation skills.
- Excellent written, verbal, and presentation skills.
- Able to demonstrate careful and authentic attention to BSWH mission, vision and values
Belonging Statement
We believe that all people should feel welcomed, valued, and supported.
Minimum Requirements
- Bachelor's or 4 years of work experience above the minimum qualification
- 10 Years of Experience