Director of Managed Care Services - Managed Care Services - Full Time/Days - Req#1980003683

Job Objective:

Under the direction of the Chief Financial Officer, the Director of Contracts assists with the negotiation; implementation, and monitoring of all managed care agreements, including contracts with health plans (HMOs/PPOs), medical groups, government agencies, and other third-party payors.

Essential Duties and Responsibilities:

• Assists with negotiation and review of proposed agreements and contract renewals with HMOs, PPOs, Medical Groups, Government Agencies, and other third-party payors.
• Conducts research prior to negotiations including analysis of historic utilization patterns and resource consumption; payment history; identification of administrative issues; and prioritizing opportunities for improvement.
• Assists with the reviews proposed contract language to validate the contract is consistent with AVH Policy and to identify opportunities for improvement.
• Prepares financial models to estimate the financial impact of contract proposals.
• Helps to identify industry trends and changes to AVH service offerings that may require changes to payment structures (i.e. Add Trauma rates; exclusions for Aphaeresis, etc.)
• Contract Management System & Data Reporting
• Maintains contract management system with support from IT Department to calculate contractual allowances and expected reimbursement.
• Maintains a shared folder on AVH Intra-Net with a summary of contract rates and terms.
• Prepares ad-hoc reports for senior management and directors of other departments.
• Monitors claim payment patterns to validate that actual reimbursement and actual referral volume are consistent with expectations and budget.
• Prepares monthly and quarterly utilization and claim payment reports for senior management in accordance with AVH Policy.
• Contract filing and tracking
• Maintains logs and tracking systems to make sure contracts make it through the approval and signature process in a timely mariner after negotiations.
• Maintains contract storage system to ensure that all managed care contracts and correspondence are properly filed and protected.

Non-Essential Duties:

• Ensures that all necessary supplies for the department are ordered and tracked.
• Participation as a Safety Officer and other work groups as requested.
• Other duties as assigned, within skill sets and abilities

Knowledge, Skills and Abilities:
Knowledge

• Working knowledge of Commercial, HMO, PPO, and Workers' Compensation reimbursement
• Working knowledge of Managed Care contract language and interpretation
• Working knowledge of Common Procedural Terminology (CPT) and ICD9/ICD10 Codes
• Working knowledge of Microsoft Office
• Knowledge of basic arithmetic

Skills

• Knowledge of basic personal computers
• Knowledge of the use of calculators
• Proficient in the manipulation and analysis of large spreadsheets and databases
• Proficient in the operation of scanners, copiers, and fax machines

Abilities

• Ability to identify and industry trends and analyze opportunities and threats to hospital reimbursement.
• Ability to make decisions and recommendations with limited or conflicting data
• Ability to handle stress
• Ability to manage a heavy caseload in an organized and efficient manner
• Ability to recommend appropriate account adjustment and write-offs
• Ability to recognize potential accounts receivable related problems and offer solutions to management
• Ability to maintain a working relationship with other departments within the organization
• Ability to review all billing transactions for accuracy, discrepancies, and appropriate charges

Core Competencies: All AVH employees will effectively demonstrate these behaviors:

Accountability

Action Oriented

Customer Focused

Compassion

Effective Communication

Teamwork

Ethics & Values

Integrity & Trust

Management Competencies: All AVH management (Supervisor, Manager, Assistant Director,

and Director) will effectively demonstrate these behaviors:

Conflict Management

Problem Solving

Timely Decision Making

Process Management

Fairness to Direct Reports

Hiring & Staffing

Developing Direct Reports

Education and Experience:

Education

• High School or equivalent
• Bachelor’s Degree in Business related field, preferred

Experience

• Previous experience working with managed care contracts and hospital claim follow up, preferred
• Minimum 2-years managed care contracting experience

Required Licensure and/or Certifications:

• None

AVH Conduct/Compliance Expectations:

• Ability to adhere with AVH Leaves of Absence Policy
• Ability to adhere with AVH Paid Time Off (PTO) Policy
• Ability to adhere with AVH Recording of Hours Worked Policy
• Ability to adhere to the department dress code
• Ability to organize work and establish priorities
• Ability to expand on own initiative in performance of duties
• Skill and ability to follow the telephone etiquette/standards
• Conforms to AVH Standards of Excellence
• Ability to function effectively under pressure and meet time parameters
• Ability to communicate effectively while maintaining good working relationships with coworkers, managers and other hospital staff
• Ability to adhere to the normal standards of courtesy and conduct as defined under the rules of hospitality at AVH
• Ability to maintain the confidentiality of patient, hospital and department information
• Ability to adhere to safety rules and regulations
• Safely and effectively uses all equipment necessary to carry out duties
• Ability to interpret and function under hospital and department policies and procedures
• Conforms with required and appropriate Joint Commission requirements
• Conforms with and supports hospital quality assurance and improvement guidelines
• Ability to participate effectively in department and hospital staff education
• Display a willingness to work as a team player
• Ability to give and support the highest level of patient/customer satisfaction at all times
• Supports and adheres to the values and mission statement established by the AVH Board of Directors

Ability to demonstrate knowledge and understanding of Corporate Compliance rules and regulations, complies with duty to report behavior standard, demonstrates understanding of purpose for Corporate Compliance

Compliance hotline and importance of seeking guidance from a supervisor when in doubt regarding a possible corporate compliance issue

Key Physical Requirements and Working Conditions:

• Work is performed in a fast paced office environment
• Work requires frequent visits to conference/office locations within the hospital
• Must be able to used standard office equipment, sit and walk to meetings.

A detailed description of the physical requirements of this job is maintained in the Employee Health Department.

Education and Experience:

Education

• High School or equivalent
• Bachelor’s Degree in Business related field, preferred

Experience

• Previous experience working with managed care contracts and hospital claim follow up, preferred
• Minimum 2-years managed care contracting experience

Required Licensure and/or Certifications:

• None