Ed Sims
Summary
Dynamic leader with extensive experience in value-based contracting and network optimization at Centene Corporation. Achieved $500M ROI through innovative clinical programs and strategic partnerships. Skilled in contract negotiation and performance management, driving high-performing teams to deliver exceptional outcomes in managed care.
Overview
31
31
years of professional experience
Work History
Enterprise Partnerships Lead
Centene Corporation
01.2023 - Current
- Retained by the Centene COO to develop and lead the Enterprise Partnership strategy for large national vendors/partners, using a plug-and-play approach to payment innovation/value-based strategy that rewards large at-risk vendors based on clinical outcomes and ROI.
- Evaluated the team, current vendors, and built an Centene/provider ecosystem that serves as a concierge single-point-of contact to markets/national population health vendors, clinical vendors for Medicaid, Medicare and Marketplace products, driving overall growth and performance.
- Recruited and built a team of 5 VPs to evaluate new clinical and supplemental vendors that manage over $10B in spend across the organization.
- $500M of run rate ROI from clinical programs under management.
- As of 08/11/2025: $150M of ROI/settlement value achieved in past 12 months.
- 300+ clinical program implementations annually.
- The clinical/UM vendors represent over 6M+ authorizations impacting $7B expense.
- Overhauled vendor intake/evaluation process that currently has an additional $6B in spend in RFPs/set to launch.
- Developed 'build vs buy' initiative that led to the termination of several large providers.
- Lead the negotiation of various renegotiation of value-based vendors to include home-health, post-acute, LTSS providers, radiology, cardiology, MSK, CKD and others.
- Annually review, along with the product teams, negotiations with existing and new supplemental vendors.
- Built strategic relationships and alliances with existing large partners.
- Terminated poor performing providers and identified low cost/high quality replacement.
- Transformed the Enterprise Partnership team.
- Directly negotiated an enterprise agreement with Availity Essentials and Editing to replace over 400 existing provider portals.
Chief Network Officer
Magellan Health (Acquired by Centene)
04.2020 - 12.2022
- Recruited by the COO to transform the network team by leveraging data with the purpose of designing and optimizing the network team and create a high performing behavioral healthcare network.
- A key executive leader that participated in the eventual acquisition of Magellan by Centene.
- Owned the performance of a network of over 140,000 providers across all 50 states.
- Responsible for providing strategic leadership as well as financial and administrative oversight of network providers, including the evaluation, negotiation, implementation, and subsequent monitoring/maintenance of both fee-for-service and value/risk-based contracting.
- Responsible for credentialing and network operations.
- Overhauled leadership network team, while maintaining top performers.
- Created a national group and facility provider partnership team that completed 1,360 provider engagement meetings in 2022 focusing on collaboration and improvement of HEDIS measures.
- Improved access to care, annual provider growth of 10% (100K+ provider base).
- Improved quality of care, reduced costs by 200+ basis points via better outcomes.
- Created strategy and led de novo sales effort hands-on for new product at high margin.
- Developed a 'Prompt Care Network' to meet the demands of pandemic related supply/demand issue.
- Moved Magellan from a low pay FFS payor rewarding providers based on value in risk markets.
- Developed both professional and facility scorecards, produced quarterly.
- Tiered network based on quality and cost.
- Paid both outpatient and facility bonuses to high performing providers.
- Provider network strategy led to the retention of our largest customer representing 32% of company revenue.
Senior Vice President, Managed Care
GLOBAL MEDICAL RESPONSE
03.2019 - 04.2020
- Company Overview: GMR is the largest air and ground ambulance company in the US and the third largest provider of risk based non-medical transportation.
- Engaged by the CFO following the merger of American Medical Response and Air Medical Group Holdings (KKR portfolio) to develop an in-network managed care strategy that incorporates payment innovation models to achieve the company’s goals.
- A member of the GMR leadership team with $4.2B in total revenue, 36,000 employees and $1.1B in managed care revenue.
- Direct the managed care revenue and contracting strategy for the enterprise.
- Developed a comprehensive managed care transformation strategy and strategic planning process for an organization that had a limited managed care participation.
- Led a team that increased the in-network percentage for air ambulance from 15% to 48% in 9 months at rates above the previous out of network rates.
- Coordinated with our non-medical managed transportation company to develop a whole health innovation strategy that includes patient-driven care and equips Medicaid members to take charge of their health and well-being.
- Developed a successful managed care strategy to target United Healthcare, Anthem and Kaiser to participate with GMR in CMS’s 'Emergency Triage, Treat, and Transport Model' (ET3) designed to give ambulance providers greater flexibility to treat low-acuity 911 calls.
- GMR is the largest air and ground ambulance company in the US and the third largest provider of risk based non-medical transportation.
Chief Managed Care Officer
LIFECARE HEALTH PARTNERS
11.2017 - 04.2020
- An integral member of the LifeCare Management team, I directed the managed care revenue and contracting strategy for the enterprise reporting to the CEO of the organization.
- Expert in complex contract negotiations and implementation, strategic planning, network acquisition/integration efforts and value-based agreements and product strategy.
- Lead a team that develops partnerships with market leading ACOs and physician groups that identifies new business opportunities.
- Developed the contracting strategy with potential joint-venture partners that allows for future development based on market reimbursement.
- Led the development of new contracting opportunities that increased revenue in that category in a challenging LTAC reimbursement environment.
- Retooled managed care department to prepare for pay for performance agreements.
- Developed key performance indicators, including real-time monitoring, gap analysis, variance mitigation strategies and processes updates.
Vice President, Managed Care
Kindred Healthcare
01.2015 - 11.2017
- Owned the ongoing relationship and strategy, both internally and externally, to expand the Kindred continuum of care in the east and over $600MM in managed care revenue.
- This included LTACs, IRFs, Sub-Acute Units, SNFs, Dialysis, Home Health and Hospice.
- I was responsible for the overall P&L performance and expansion of partnerships to additional product lines while executing a value-based strategy.
- The operations lead for credentialing, and new ACO, MSO and delegated physician group contract opportunities, which included contracting, network development and product strategy.
- Lead a team that assess the current service strategy and operational objectives to determine contract, network development priorities, and recommend growth and expansion targets, new markets, product line enhancements and service innovations.
- Leverage experience in building contracting and organizational infrastructure for success in at-risk payor agreements for successful population health management.
- Foster deep relationships/partnerships with key payers and critical third-party MSO relationships.
- Proactively meet with C-Suite leaders at key payers to identify opportunities for broader collaboration and partnership, including both regional and national health plans.
- Maintain ongoing relationships with payers, monitor.
- Identify and sell value-based care that aligns incentives to create win-wins.
- Re-designed existing team to create an organization that sells on value.
- Assume ownership for additional ACO relationships as they are finalized.
Vice President, Network Operations
Univita Healthcare Solutions
12.2012 - 01.2015
- I was promoted to lead the national Network Operations, Provider Relations and Account Management at Univita to expand and manage the delegated functions of the organization with over 10M full-risk capitated lives.
- In this role, I was responsible for the complete management, development and oversight of Network Operations and our managed care strategic account strategy.
- The team was responsible for organic growth, new business development, downstream contracting, Provider Relations and health plan expansion with an emphasis on post-acute care.
- Collaborated cross functionally to ensure all intersecting functions performed by Network favorably impact other operations/services within the organization, i.e., claims, clinical, customer service, fraud and abuse, etc.
- The position included managing budgeted financials of the strategic accounts department (7 employees), network operations (17 employees), credentialing (9 employees) and provider relations (12 employees).
- Assess the current service strategy and operational objectives to determine network development priorities and recommend growth and expansion targets, new markets, product line enhancements and service innovations.
- Coordinated with the VP of Clinical Health Services Management (CHSM), medical and pharmacy directors, to provide strong leadership in implementing initiatives and strategies to control medical costs to achieve budgeted medical cost targets.
- Expanded provider network to accommodate 1M new full risk lives.
- Managed 2,500 network providers, including 3 large sub-capitated providers.
- Developed key relationships with strategic delegated MSOs, IPAs, physician groups and integrated delivery systems.
- Managed hospital executive relationships.
- Re-negotiated 7 contracts in four months that were losing over $8M annually to a projected $3.2M FCF.
Vice President, Market Network Expansion
Univita Healthcare Solutions
12.2012 - 06.2013
- I was recruited by the Univita CEO to expand Univita’s full risk business in new markets.
- Conceived, fostered and launched a national product line exceeding growth development projections.
- Launched Univita’s expansion into the Texas and Tennessee markets, exceed expectations and above margin (MLR) expectations.
- Led effort to create a statewide network on both a FFS and sub-capitation bases.
- Led the development of Univita’s first hospital joint venture partner SCL (Sisters of Charity of Leavenworth) in Denver, CO from development to acquisition and launch.
Vice President, National Accounts
Philips Healthcare / Philips Home Healthcare Solutions
09.2007 - 12.2012
- Responsible for the complete management and oversight of the managed care strategic account strategy and executive relationships within the managed care, home healthcare, medication adherence and senior living channels in the US.
- The team was responsible for organic growth, new business development and channel expansion.
- The position was an individual contributor and includes managing budgeted financials of the Strategic Accounts department (17 employees, including six Senior Managers).
- Assess organizational, divisional, and community needs and develop short- and long-range plans for services in collaboration with the executive team, accounts and institutional partners.
- Acted as consultant to homecare customers to assist in meeting their home health growth goals.
- Managed the largest most profitable Philips accounts with a DM of 34% (compared to company at 26%).
- Negotiate contracts, implement and measure to ensure optimization of signed agreements.
- Initiated mission synergistic solutions that create win/win for accounts and Philips.
- Exceed revenue and growth goals 2007-2012 (YTD).
- Only VP within division to exceed in each year.
- Revenue growth exceed 6%+ at Philips HM for strategic accounts in 2008, 2009, 2010 and 2011.
- On track to overachieve Q1 2012 revenue target (111% YTD).
- Took over struggling Senior Living division in 12/09. Finished 2010 at 105% to goal, 2011 YTD 105%.
- Achieved Philips Presidents Achievement Award 3 years (3 out of three times eligible) for my business units exceeding sales & revenue goals.
Vice President, Business Development
Amedisys Home Health Care, Baton Rouge, LA (AMED)
01.2005 - 01.2007
- Directed the overall home health organic growth of the organization and managed care contracting within fourteen of the 22 states AMED operates.
- Responsible for $520MM in revenue and a department budget of $1.4M.
- Responsible for establishing the short and long-range growth objectives, including expansion and enhancement of managed care contracts, quality care initiatives and developing partnerships with physicians, senior living organizations, hospitals and rehab providers that improve patient care service and add shareholder value.
- Led the implementation of companywide National Account and managed care plan.
- Responsible for leading and coaching a team of 13 Area Vice Presidents.
Director, Managed Care
Davita / Gambro Healthcare (DVA)
01.1998 - 01.2005
- Directed the Managed Care and Strategic Account contracting strategy of dialysis and laboratory services to payors, employers, correctional institutions, hospitals, physicians and medical groups in the West.
- Duties included supervision of Contract Managers and Contract Representatives, contract and financial analysis, contract management, pull-through sales, strategic planning, joint venture improvements and contract negotiation in a multi-State division.
- Responsible directly and collaboratively for the achievement of targeted revenue per treatment.
- Directly and collaboratively responsible for referral development strategies and renegotiating targeted contracts that assisted in raising the revenue per treatment.
- Directly and collaboratively responsible for over $5M in incremental revenue straight to the bottom line for the West Division (2003).
- Organized collaborative teams in conjunction with operations to produce effective cost analyses, develop pricing strategies and monitor the revenue impact of sales efforts.
- Responsible for re-negotiating several Medicare Advantage contracts in 2003-05 at rates more than the Medicare allowable that touched over five hundred patients.
- Negotiated more than 170 new profitable contracts in twenty-five different states.
- Effectively monitored the performance of contracts and sales strategies to track financial impact, contribution to market share and administrative impact.
Contract Manager
US Oncology / Physician Reliance Network
01.1995 - 01.1998
- Directed all Regional and National key account and managed care sales in a multi-state Region for the Nation’s largest Oncology Physician Practice Management Company with an aggressive approach of obtaining full risk (approximately 1M capitated lives).
- Responsible for all managed care negotiations and referral development in support of over 120 Oncologists, Hematologists, Radiation Oncologists and six full-service radiation centers.
- Implemented program to develop and build 'messenger model' IPA networks.
- Negotiated over 50 regional, state-wide and national agreements.
- Developed targeted pull through strategies by physician market.
- Negotiated and managed capitated contracts.
- Participated in the transition of several large acquisitions while increasing contracted revenue and market share.
Education
B.A. - Communications
Texas State University
San Marcus, TX01.1989
Skills
- Value-based contracting
- Network optimization
- Performance management
- Clinical program evaluation
- Contract negotiation
- Managed care strategy
Accomplishments
- Directly responsible for over $10B in medical spend with a validated pipeline of $6B to launch.
- Achieved Philips Presidents Achievement Award 3 years (3 out of three times eligible).
- Only VP at Philips HM that exceeded 105% of revenue goals in 2008, 2009 and 2010.
Timeline
Enterprise Partnerships Lead
Centene Corporation
01.2023 - Current
Chief Network Officer
Magellan Health (Acquired by Centene)
04.2020 - 12.2022
Senior Vice President, Managed Care
GLOBAL MEDICAL RESPONSE
03.2019 - 04.2020
Chief Managed Care Officer
LIFECARE HEALTH PARTNERS
11.2017 - 04.2020
Vice President, Managed Care
Kindred Healthcare
01.2015 - 11.2017
Vice President, Network Operations
Univita Healthcare Solutions
12.2012 - 01.2015
Vice President, Market Network Expansion
Univita Healthcare Solutions
12.2012 - 06.2013
Vice President, National Accounts
Philips Healthcare / Philips Home Healthcare Solutions
09.2007 - 12.2012
Vice President, Business Development
Amedisys Home Health Care, Baton Rouge, LA (AMED)
01.2005 - 01.2007
Director, Managed Care
Davita / Gambro Healthcare (DVA)
01.1998 - 01.2005
Contract Manager
US Oncology / Physician Reliance Network
01.1995 - 01.1998
B.A. - Communications
Texas State University