Managed care

JOB SUMMARY

The Managed Care Resource will support our Home Health, Hospice, Private Duty and Senior Living Facility leaders in managed care contracting and revenue enhancement strategies for all healthcare payers as well as assist in the preparation for changes in the healthcare industry.

The Consultant will negotiate managed care payer contract rates and terms and provide guidance with regards to the development of managed care relationships, ensuring timeliness and appropriateness of negotiated rates.

Additionally, the Resource will negotiate contracts for new locations, assist with ensuring that contracts are updated for new services and help with contract cancellations, denials, appeals and high level contract payment disputes.

DUTIES & RESPONSIBILITIES

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Establish, plan, direct and evaluate the implementation of tactical plan(s) that will ensure expansion and support of business operations into managed care relationships and brings consistency of contract-related criteria and guidelines to optimize financial performance and minimize risk for operations.
• Assist in analysis of contract terms and rates and coordinating the submission of amendments, changes in reimbursement, language changes and assist in advising each operation of risks and advantages of signing contracts.
• Identify, develop and maintain an effective relationship with managed care payors and managed care / health care regulatory agencies.
• Provide guidance and training when applicable to assist Field Operations partners in order to assist in accelerating the results of the Field.
• Monitor industry changes, market trends and events to proactively identify opportunities to increase and protect the operations managed care revenue as well as present as subject matter expert with regards to applicable changes in the healthcare industry.
• Coordinate and assist each operation with any issues such as contract cancellation and denials / appeals.
• Effectively communicate at all organizational levels and in situations requiring education, consultation, instruction, persuasion, negotiation and advisement as Consultant will serve as internal managed care subject matter expert to Presidents, Executive Directors and Service Center leadership personnel.
• Teach, train and advise operational leadership on how to administer their managed care contracts by the creation and distributions of tools, training and resources for leadership, AR team, Intake personnel, Case Management and all other Operations or Service Center team members as needed.
• Assist AR team with high level managed care claims issues and projects to ensure timely collection of monies due.
• Serve as primary liaison for all operations by distributing to operations and service center all key contract terms and rates for all new and existing managed care payer contracts.

JOB REQUIREMENTS (Education, Experience, Knowledge, Skills & Abilities)

• Bachelor’s degree in business administration, management or health care administration preferred.
• 5 years’ experience in managed care contracting with a managed care payer or provider organization.
• Analytically oriented with the ability to communicate complex financial matters in a concise, professional manner.
• Must be knowledgeable about the managed care environment; including Medicare Advantage, Commercial and Managed Medicaid products (HMO, PPO, EPO, POS and Special Needs Plans) as well as knowledge of Accountable Care Organizations (ACO’s).
• Work collaboratively as part of the Managed Care Team.
• Knowledge of managed care payer contract language and terms, standard requirements and negotiated rate methodology to support contract compliance and analysis.
• Must be able to prioritize, plan, and handle multiple tasks / demands simultaneously and have strong analytical and problem solving skills with keen attention to detail and an aptitude for accuracy.
• Excellent verbal and written communication skills, as well as excellent critical thinking skills.
• Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
• Knowledge of Home Health, Hospice, Private Duty and Assisted Living Facility operations is a plus.
• Ability to be flexible, adaptable, and work in a rapidly and constantly changing environment
• Knowledge of CPT-4, HCPCS, Revenue and ICD coding.
• Strong computer skills (MS Word, MS Outlook & Excel) with Smartsheet knowledge a plus.
• Must be able to travel.

Please note this job description has been designed to indicate the general nature, working conditions and level of work performed by employees within this job.

It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities, working conditions and qualifications required of employees assigned to this job.

Duties, responsibilities and activities may change at any time with or without notice. Additionally, the incumbent may be requested to perform job-related tasks other than those stated in this description.

Last updated : 2024-03-09