POSITION SUMMARY:
The Senior Director, Managed Care Contracting is a high visibility leader responsible for administering, coordinating, and negotiating on behalf of the Company entities in their respective Group, Region or Markets, and have the responsibility for either oversight or direct negotiating involvement in all Managed Care negotiation and contracting activities consistent with the Managed Care strategies and business and financial plans established by the Managed Care and Operations teams.
ESSENTIAL FUNCTIONS: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.
- Oversee and participate in the development, negotiation, implementation, monitoring and management of all Managed Care agreements; these agreements include more traditional fixed rate fee schedules as well as value based care agreements across all provider care settings.
- Lead significant dollar and volume contracts and oversee that the proper Managed Care Data, Information, and Financial Systems supporting these discussions is provided in the formats necessary for strategic and operational insights required for a beneficial negotiation.
- Evaluate and recommend financial parameters and reimbursement methodologies.
- Implement new Managed Care programs in conjunction with staff and hospital administration. Keeps staff apprised of developments in the Managed Care marketplace.
- Direct and participate in financial analysis of revenue projections based on contractual rates with payers, adverse trends, terms and appropriate recommendations or conclusions.
- Analyze and monitor financial aspects of existing Managed Care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements.
- Oversee the audit of payer fee schedules based on negotiated reimbursement rates by contract and/or product line
- Maintain and distribute participation information by payer by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated.
- Responsible for reviewing Managed Care legal contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies.
- Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance and value based reimbursement initiatives.
- Assemble information and prepare materials for presentation to committees, administrators and manage care networks
- Liaison with hospitals, other affiliated organizations and Managed Care organizations regarding issues pertaining to Managed Care.
- Initiate contact with Managed Care Plans to begin negotiation re-negotiation process.
- Catalog and organize contracts along with helping maintain contracts data base and maintaining Managed Care data base.
- Work and manage Data Analyst to establish negotiating position and work with Revenue Cycle department to assure contract compliance.
- Coordinate Physician contracting with hospital and ancillary agreements.
- Regular and reliable attendance.
- Perform other duties as assigned.
Additional Information:
- Position serves both internal co-workers and external customers, clients, patients, contractors, and vendors.
- Access to and/or works with sensitive and/or confidential information.
- Exhibit a comprehensive understanding of healthcare regulatory and compliance (e.g., HIPAA). Skilled in the application of policies and procedures. Knowledge of Business Office Standards and Recommended Practices.
SUPERVISORY RESPONSIBILITIES:
Manage the work of others, including planning, assigning, scheduling and reviewing work, ensures quality standards. Responsible for hiring, terminating, training and developing, reviewing performance and administering corrective action for staff.
Qualifications - External
KNOWLEDGE, SKILLS & ABILITIES: The requirements listed below are representative of the knowledge, skills and/or abilities required.
Education: Bachelor's Degree.
Experience: Minimum of 10 years in Hospital or Health Plan experience with knowledge of contractual, administrative, health insurance and operational issues related to Managed Care organizations, physician groups, hospitals and health insurance benefit plan designs.
Certifications: N/A
Licenses: N/A
Skills and Abilities:
- Business Mathematical Skills -- Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rates, ratios, and percentages and to draw and interpret graphs.
- Moderate Computer Skills -- Frequent use of electronic mail, word processing, data entry, spreadsheets, graphics, etc. Ability to create, maintain and incorporate simple functions into documents, spreadsheets, databases, and presentations to support business objectives.
- Complex Communication -- Frequently communicates complex information and interacts with management. Can present, resolve, and address delicate situations. Can motivate and persuade others.
- Varied Business Problems -- Problems are varied and complex, requiring analysis or interpretation of the situation. Problems are solved using knowledge and skills, general precedent and practices.
- Department Specific -- Decisions impact the management and operations within a department. May contribute to business and operational decisions that affect the department.
- Functional Independent Judgement -- Provides and sets goals and priorities for functional area. May make recommendations for department policies, practices, and programs. Makes decisions for and/or resolves problems for others.
- Project Planning/Organization -- Handle multiple projects simultaneously including task delegation, project oversight, and resource allocation.
PHYSICAL AND MENTAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job responsibilities.
While performing the duties of this job, the employee is occasionally required to stand; walk; sit for extended periods of time; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, bend, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 20 pounds. Repetitive motion of upper body required for extended use of computer. Required specific vision abilities include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
WORK ENVIRONMENT AND TRAVEL REQUIREMENTS:
Work environment characteristics described here are representative of those that an employee may encounter while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job responsibilities.
Works in well-lit, ventilated and climate controlled office environment with routine office equipment; some equipment has moving mechanical parts.
In hospital environment, may be exposed to hazards and unusual elements, which may include but are not limited to bloodborne pathogens and / or contagious illnesses, toxic chemicals, and biohazardous materials which may require extensive safety precautions and the use of protective equipment.
Noise level in the work environment is typical for an office and/or hospital environment.
Extensive overnight travel (over 50%) by land and/or air.