Senior Executive Manager - PR Contract Management

Position Overview

We are seeking a highly motivated and strategic Senior Executive Manager - PR Contract Management to lead the end-to-end contract management and network design initiatives for our organization. In this pivotal role, you will be responsible for implementing and overseeing the execution of the provider strategy and framework, ensuring full compliance with CCHI and SAMA regulations while driving effective price and cost management. Your leadership will be instrumental in delivering substantial project savings, fostering business profitability, and supporting the expansion of our insurance market presence. This position requires a dynamic professional who can collaborate closely with sales, marketing, and commercial finance teams to continuously develop innovative products and services that align with market demands and strategic business objectives.

Key Responsibilities

Contract Management

You will establish and enforce robust contract rules and standards with all providers to safeguard the best interests of the business. This includes supervising the contracting process for new providers, service codes, and contract renewals, ensuring strict adherence to regulatory requirements, renewals, and licensing obligations. Your role will involve actively engaging in negotiations to secure favorable terms and conditions that support the organization’s financial and operational goals.

Benchmarking and Pricing Excellence

To ensure competitive and fair pricing, you will introduce comprehensive benchmarking systems for frequently billed items, both regionally and within specific networks. You will develop processes, references, and guidelines for non-benchmarked items to enable reasonable and equitable pricing for members and internal stakeholders. Additionally, you will create pricing models, guidelines, and benchmarks for specialized services such as optical and other unique offerings. This includes revamping the coding system to eliminate redundancy and duplication, implementing business obligations for ICD 10-am systems, and resolving issues related to invalid, duplicate service codes, and overbilling.

Cost Effectiveness and Negotiation

Your strategic approach will drive the development and implementation of price reduction plans to achieve predefined business targets. You will negotiate with providers to bundle services (inpatient and outpatient) and expand surgical packages, ensuring that pricing for new and renewed contracts aligns with established benchmarks and business goals. Regular price forecasting will be provided to stakeholders to support informed decision-making and financial planning.

Network Design and Optimization

You will ensure that the provider network is comprehensive, accessible, and tailored to meet the benefits requirements of each customer class. This involves regularly enhancing the network through strategic upgrades or downgrades based on risk, cost, and business needs. Your responsibilities will include optimizing networks for optical and dental providers, managing pharmacy benefits (including formularies and refill systems), and ensuring the network remains cost-effective and aligned with market demands.

Volume Allocation and Service Innovation

To maximize efficiency and cost-effectiveness, you will enhance the stepladder referral system with regular updates, develop networks of anchor providers and centers of excellence, and manage volume reallocation between providers as needed. You will explore and implement innovative payment approaches, such as paradigm shifts, prepaid services, and accountable care organizations, to support business growth. Additionally, you will foster strategic partnerships with key providers and develop tools such as physicians and service finders to enhance customer experience and operational efficiency.

Coordination, Communication, and Leadership

Effective communication and coordination are critical to this role. You will ensure that contract additions, deletions, amendments, and significant milestones are promptly communicated to operational teams and technical stakeholders. Regular price forecasts will be shared with commercial finance, while network redesigns and referral system updates will be communicated to operations and sales teams. Collaboration with sales, marketing, and commercial finance will be essential to align volume reallocation, healthcare plans, and network updates with business objectives. As a leader, you will provide professional guidance, direction, and mentorship to your team, fostering a culture of excellence and accountability.

Qualifications and Experience

• Bachelor’s degree in Business Administration, Healthcare Management, Finance, or a related field; a Master’s degree is preferred.
• Minimum of 10 years of progressive experience in contract management, pricing strategy, or network design within the healthcare or insurance industry.
• Proven track record in negotiating complex contracts, reducing costs, and driving operational efficiencies.
• Strong understanding of regulatory compliance, particularly CCHI and SAMA requirements.
• Exceptional analytical, strategic planning, and leadership skills.
• Excellent communication and stakeholder management abilities.
• Proficiency in financial forecasting, benchmarking, and data-driven decision-making.