Managed Care Director

Overview

In-Office Position

Employment Type: Full Time


Benefits : M/D/V, Life Ins., 401(k), PTO, Paid Holidays


Northwest Cancer Centers is the most advanced oncology group in Northwest Indiana. Our physicians have combined decades of experience and received their training at highly acclaimed research institutions both nearby in Chicago and across the world. Our Gynecologic Oncology team offers an integrative approach to the diagnosis, treatment and surgical management of women cancers. Our focus as physicians is to give you the right diagnosis and guide you as medical experts. We take pride in using a comprehensive approach towards our patients' health. We believe that long-term care after cancer treatment is as important as your current treatment.

SCOPE:

This role leads direct contracting with self-funded employers and employer coalitions to establish Preferred Oncology Provider relationships and is also accountable for traditional managed care contracting with commercial health plans and Medicare Advantage organizations, and provider partners including hospitals and PCP networks and employers. Directs the formulation and execution of all managed care initiatives and strategies that will maximize opportunities with third party payers, including direct-to-employer opportunities, and provider partners including hospitals and PCP networks and employers statewide. Oversees managed care related policies, procedures and processes in support of strategic objectives. Develops and executes in conjunction with members of the US Oncology Network support staff on practice strategic planning and both long and short term goals to position [Practice] optimally within the direct-to-employer, third party payer environment, and local hospital/provider market.


The individual prepares budget and advises senior management both within the US Oncology Network and practice leadership on all matters concerning net revenues in the areas of Commercial Managed Care, Medicaid and Medicare. Develops and maintains employer and payer relationships and advocates for the community-based oncology agenda with payers locally, identifying opportunities for enhanced relationships, reimbursement, referrals and a growing market presence. Overall, responsible for directing all contract negotiations and strategies to support revenue growth for assigned practices.

Operationally executes strategies and negotiations to support alternative payment models with a focus on focus on employer preferred provider and novel payment models such as value-based reimbursement methodologies (i.e., case rate development, integrated networks, contract capitation, total cost of care initiatives and shared savings models) and has a firm grasp on the analytics/practice impacts that support such payment models. Serves as "expert" advisor to assigned practices regarding maximizing revenue from managed care products and Medicare and Medicaid programs. Develop and make recommendations regarding changes needed to enhance and optimize physician income and overall practice revenues.


You will collaborate with multiple internal groups which contribute to this business (US Oncology operations, Onmark operations, GPO, Pharmacy Solutions, Oncology Intelligence & Analytics, VBC Transformation, and Medically Integrated Pharmacy, Business Development) to develop preferred provider agreements and alternative payment models and ensure delivery of compelling performance which results in gain share and optimization of quality measures. This includes incorporation of practice reporting, outcomes measures, etc. developed and used in support of such practice initiatives. Includes leadership and a focus to support risk-based contracts, claims studies, actuarial evaluations and episodic payments where gain share (or upside), steerage and other upside to the practice are included.


The individual creates a shared vision and demonstrates the ability to clearly articulate the organization's desired position, creates a common goal for unity among groups with diverse interests and beliefs, clearly communicates the organization's mission, strategies, goals and priorities, defines team members' roles and responsibilities, seeks input and buy-in from team members and establishes alignment throughout the organization.


Responsibilities

KEY RESPONSIBILITIES:

-Plans, develops, directs, coordinates and monitors all managed care activities to successfully bring to market new products, methodologies, and strategies and to negotiate compelling contracts with both payers, including direct-to-employer opportunities and providers (where appropriate).

-Works with assigned practices and McKesson operations, finance, Managed Care team and the pharmacy team, directs and advises on strategies and solutions, and sets benchmarks to ensure that contracts negotiated in accordance with budgeted objectives to obtain maximum profitability and volume in relation to pre-set standards and specific trends within the industry.


-Collaborates with practices to establish annual Managed Care and Value Based Care Budget and record results in organization tracking system.

-Evaluates practice trends and variances to plan and provide information to senior management and field. Communicates and educates all internal customers as to the prudent and most effective manner with which to deal with payers and situations.

-In coordination with the revenue cycle leadership, evaluates, sources, designs, recommends and monitors the execution and effectiveness of policy, procedure and processes designed to ensure timely and accurate reimbursement of payers.

-Takes responsibility for and coordinates the execution of all assigned practices' tactical and strategic payer initiatives including responsibility for creating and maintaining positive external relationships with all relevant payers, providers, health systems and employers, where relevant.

Qualifications

MINIMUM QUALIFICATIONS:

10+ years of professional experience related to direct-to-employer contracting, managed care, value-based care, healthcare administration, payer relations, or oncology or multispecialty practice operations.

EDUCATION:

-Bachelor's Degree required

-Master's in Finance, Business or Healthcare Administration preferred

CRITICAL SKILLS:

-Experience working for a community-based health provider or related consulting organization, preferably in direct-to-employer contract negotiations or value-based care


-Strong understanding of strategic and operational considerations for healthcare providers

-Experience developing relationships with high level, decision-makers in the payer, third-party administrator and specialty practice environments with a track record of innovative network development and contracting solutions

-Experience in healthcare management in a managed care environment including significant experience in commercial payer strategies, pricing, reimbursement and healthcare costing analysis

ADDITONAL SKILLS:

-Knowledge with coordinating activities, exchanges information and clarifies needs from a Managed Care perspective with Marketing, Business Development, Finance, Revenue Cycle Management, Pharmacy Operations and the Clinical Team.

-Experience in Oncology or specialty practice environment

-Experience and knowledge with strong executive presence, exceptional leadership skills and superior organization skills

-Expertise in fee-for-service and value-based care contracting with ability to advise specialty practices

-Strong understanding of strategic and operational considerations for healthcare providers

-Ability to work collaboratively in a team environment

-Ability to work effectively with people at all levels in an organization

-Ability to influence people, build relationships and collaborate

-Proficient in public speaking and facilitating large groups remotely

-Experience in developing content to engage large groups remotely

-Experience monitoring markets, industries, and companies to maintain and updated information base by participating in industry organizations including developing new contracts, knowledge and trends to cultivate new strategies

-Proficiency in Microsoft Office Suite and Salesforce

TRAVEL:

Office-based role with regular travel to meetings with local strategic partners and occasional domestic travel.

PHYSICAL 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 functions. While performing the duties of this job, the employee is regularly required to sit and use hands to finger, handle, or feel. The employee is occasionally required to stand, walk, and reach with hands and arms. The employee must occasionally lift and/or move up to 30 pounds. Requires vision and hearing corrected to normal ranges.


WORK ENVIRONMENT:


The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Work is performed in an office environment and requires significant interaction internally with corporate and field management staff and externally with clients and customers.