Careers

Current openings:

 

Location: Research Triangle Park, NC

Position Purpose:  Join Carolina Complete Health Network in building an organization in which our team exceeds our stakeholders’ expectations and our Pay for Performance model will reward team members who continuously do so.

Reporting to the Chief Executive Officer (CEO), direct and coordinate Carolina Complete Health Network’s medical policy function.

  • Directs and coordinates the process to develop medical policies.
  • Works with Carolina Complete Health Network’s CEO and Carolina Complete Health’s  Chief Medical Officer to coordinate the activities of the advisory committees established by Carolina Complete Health’s Medical Affairs Committee; including committee structure, processes, and membership.
  • Assists Carolina Complete Health Network’s CEO and Carolina Complete Health’s Chief Medical Officer in planning and establishing goals and policies to improve cost-effectiveness of care and service for members.
  • Facilitates the adoption of clinical practice guidelines.
  • Collaborates with health plan, internal, and external stakeholders to develop policy agendas.
  • Provides medical leadership for utilization management, cost containment, and medical quality improvement activities.
  • Assists in performing medical review activities pertaining to utilization review, quality assurance, and medical review of complex, controversial, or experimental medical services.
  • Supports effective implementation of performance improvement initiatives for providers of the healthcare network.
  • Provides medical expertise in the operation of approved quality improvement and utilization management programs in accordance with regulatory, state, health plan, and accreditation requirements.
  • Directs the development and implementation of physician education with respect to clinical issues and policies.
  • Identifies utilization review studies and evaluates adverse trends in utilization of medical services, unusual provider practice patterns, and adequacy of benefit/payment components.
  • Identifies clinical quality improvement studies to assist in reducing unwarranted variation in clinical practice in order to improve the quality and cost of care.
  • Interfaces with physicians and other providers in the provider network in order to facilitate implementation of recommendations to providers that would improve utilization and health care quality.

Minimum Qualifications:

  • Nurse Practitioner, Registered Nurse or Physician Assistant.
  • Active state medical license without restrictions.
  • Course work in the areas of Health Administration, Health Financing, Insurance, preferred.
  • Experience treating or managing the care for a culturally diverse population preferred.
  • Previous experience with managed care organization preferred.
  • 10+ years of experience.

To apply, click here (External Link).

Carolina Complete Health Network is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristics protected by applicable law.

Location: Charlotte

Position Purpose: Join Carolina Complete Health Network in building an organization in which our team exceeds our stakeholders’ expectations and our Pay for Performance model will reward team members who continuously do so.

Reporting to the Senior Director, Network Development, the Manager, Contract Negotiator coordinates and negotiates hospital, physician (IPAs, PPMs, individual providers, multi-specialty groups) and ancillary service agreements that are in accordance with Carolina Complete Health Network, Carolina Complete Health, and State guidelines.

Develops healthcare provider network plan for region and set of providers.

  • Identifies, negotiates, and manages complex contractual arrangements with providers.
  • Leads assigned negotiations (i.e., hospital, physician, ambulatory surgical centers, and ancillary) and ensures that negotiations result in the unit cost targets expected and meet the objectives of Carolina Complete Health Network.
  • Develops and maintains relationships with physician and business leadership of key physician groups, hospitals, and integrated delivery systems.
  • Facilitates and provides oversight to the provider set-up and contract configuration to ensure accurate claims adjudication and adherence to legal and regulatory standards prior to execution.
  • Evaluates and monitors providers’ performance standards and financial performance of contracts, renegotiates where applicable and applies managed care reimbursement principles (value-based initiatives, capitation, case rates, creative reimbursement, etc.) to maximize cost savings.
  • Identifies medical cost improvement opportunities.
  • Assists with and tracks credentialing activities.
  • Facilitates the organization of provider focus groups.
  • Coordinates with internal departments and contracted healthcare providers to implement and maintain contract compliance.
  • Participates in organizational audits to ensure organizational compliance with regulatory agencies as appropriate.
  • May require up to 25% travel

Minimum Qualifications:

  • Bachelor’s degree in Healthcare Administration, Business Administration, Marketing, related field, or equivalent experience.
  • 5+ years of contracting, provider relations or other related experience preferably in a healthcare, managed care, or insurance related environment.
  • Excellent written, oral, and presentation skills.
  • Ability to work collaboratively with staff and contractors at all levels.
  • Well developed organizational skills and attention to detail.
  • High proficiency with Microsoft Office products, as well as communication productivity tools.

To apply, click here (External Link).

Carolina Complete Health Network is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristics protected by applicable law.