Senior Director of Managed Care Contracting

Description

Job Overview:

The Director of Managed Care Contracting is accountable for achieving financial and business objectives for the organization with a focus on compliance, network management, and value-based agreements. The Director of Managed Care Contracting is accountable for implementing and supporting payor and provider contracting to achieve the optimal financial and operational performance goals of the organization.

Qualifications

Primary Responsibilities:

• Review and evaluate contract language and reimbursement terms in existing and potential managed care agreements, and to make recommendations required for the benefit of the organization.
• Provide support and expertise in developing and analyzing large and complex data sets for the creation of financial rate models, make proposal recommendations in negotiating/renegotiating and implementing rates and terms for health plan contracts, ensuring key operational and financial budget objectives are met.
• Prepare financial reports to review and assess utilization trends and overall financial performance of contracts, and identify improvement opportunities with rates/contract language, with the development of action plans to carry out improvements.
• Responsible for contract performance (manage contract operating costs, optimize performance of quality and productivity) and supports the development and implementation of value-based contract relationships in support of business strategies.
• Assists with the design, development, management, and/or implementation of strategic network configurations and integration activities.
• Collaborates cross-functionally to support provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reporting.
• Supports evaluation, development, and implementation of the provider network strategic plan(s) to achieve contracting targets and manage medical costs through effective provider contracting to meet state and federal compliance.
• Maintains accurate centralized contracting repository, including contract documents, provider data & reporting.
• Assures compliance with Clinically Integrated Network structure across all organizations.
• Collaborates with internal partners to assess effectiveness of tactical plan in managing costs.
• Ensures resolution of escalated issues related to contract interpretation and parameters.
• Interprets contractual requirements including federal and state regulations and NCQA.
• Facilitates and manages deliverables for payer JOC meetings.
• Assures adherence to accreditation and regulatory standards for network management, credentialing, and re-credentialing.
• Assure accurate implementation of contracts in addition to working with other departments to assure that contracts are successfully administered.
• Maintain an awareness of the evolving healthcare industry and translate knowledge into business opportunities. Maintain a working knowledge of applicable Federal, State, and local laws and regulations.
• Active Role in the Net Revenue Budgeting, Long Term Planning, and the Strategic Planning
• Develop and maintain strong inter-company relationships that facilitate the monitoring of payer issues such as but not limited to payer provider participation status, market rate analysis, contract loading and payment issues.
• Prepare internal training or educational tools as they relate to health plan contracting and /or payment policies.
• Perform other job-related duties and projects as assigned.

Job Requirements:

• Bachelor’s degree in business or related field. Preferred master’s degree in relevant subject area such as Business Administration and Health Care Administration.
• 5-7 years of progressive experience in provider network development, contract negotiations with multi-payer environment, including value-based arrangements and urgent care and primary care contracting.
• Possess a strong understanding of the healthcare industry and payor-provider reimbursement methodologies as well as pricing strategies.
• Superior strategic and critical thinking skills.
• Ability to effectively communicate at all levels of the organization.
• Excellent written and oral communication skills including presentation skills.
• Proficient experience with Microsoft Office including Excell, Word, PowerPoint, etc.
• Excellent teamwork and leadership skills.
• Strong Analytical thinking, multi-tasking, organizational and time management skills.