Director, Managed Care

Description

Salary Range: $196,000.00 - $294,000.00

Washington Hospital Healthcare System Job Description  

Job Code: 714  

The Director, Managed Care Contracting, contributes to WHHS’ growth  

Job Title: Director, Managed Care Contracting  

Position Summary  

The Director, Managed Care Contracting, contributes to WHHS’ growth and profitability by providing contracting expertise to existing and new contractual relationships; and providing subject matter expertise, guidance, and direction regarding Managed Care Contracts.This includes coordination of commercial, Medicare Advantage, Medi-Cal Managed Care, Value-Based, Medicare Shared Savings, and other third party managed care contracts and Payor relation activities for Washington Hospital, Washington Township Medical Foundation, and DEVCO entities (surgery centers and other ancillary entities).The Director will be responsible for overseeing administration,review,andfinancialanalysesofmanagedcarecontractsfor the healthcaresystem, performingfinancialreportingandfinancialmodelingforseniormanagementstrategicmanagedcaredecisionmaking, and overseeing all Payor relations and managed care denial follow-up and resolution activities for the health care system.  Inadditiontoperformingtheessentialfunctionslistedbelow,mayalsobeassignedotherdutiesasrequired.

 

Statement of Accountability:

Reports to: Vice President & Chief Revenue Officer  

Qualifications 

• Education:

Required:  Bachelor'sdegree (minimum ten 10 years’ experience can be substituted for formal education). 

Desirable:  Master'sdegreeinhealthrelatedfield 

• Experience: 

-Minimum seven (7) years in a Managed Care Contracting capacity within a health plan or hospital; and at least the five (5) years of experience managing and mentoring Contract Manager or Payor Relations representatives.

-Experienceinanadministrativelyresponsiblepositionwithsignificantintra-departmentwork. 

-Demonstratedinterpersonalskills. 

-Demonstratedskillinworkingwithalargevarietyofpeopleofvariousorganizationsandlevels. 

-Knowledgeoflegalterminology,understandingofgovernmentalandlegislativeregulations. 

-Previousexperienceintheareasofmanagedcare/finance/or patientaccounting. 

-Demonstratedabilitytoperformfinancialanalysis,including managed care contracting financial modeling. 

-ComputerSkills:  FinancialModeling,Windows2000, Excel,2000,Work2000,PowerPoint. 

• SkillsandAbilities: 

-Mustpossesstechnicalandprofessionalskillsand knowledgeoffinance,patientaccountingfunctionsandmanagedcare.  Mustpossessstronginterpersonalskills,beaneffectivepublicspeakerandbecomfortableinworkingwithdiversegroupsofindividuals.  MustbeabletocompetentlyrepresentWashingtonHospitalatadministrativefunctions. Mustbeabletoworkindependentlyandcreatively.

EssentialJobResponsibilities 

• Responsible for negotiating Managed Care Contracts.This includes routine contracting activities, maintaining strategic relationships, evaluating contracts, and acting as an internal resource in interpreting contracts.
• Responsiblefortheinitialreadingandfinancialanalysisofmanagedcarecontractsforcontent,administrative issues,andappropriatefinancialreturn. 
• Evaluatefinancialperformanceofexistingcontractualrelationshipsandmonitorperformanceofnewcontractualrelationships.  Thisincludesproductionoffinancialimpactreports onanongoingbasisbybothPayorandmedicalgroup.
• Working closely with Managed Care and Finance leadership to develop contract proposals based on WHHS’ defined strategies, goals and objectives.
• Working closely with WHHS Strategy to participate in Employer Direct contracting, contracting for new WHHS services, and other strategic growth initiatives that require managed care contracting support.
• Preparehistoricalandfinancialdatatoprovidesupportfor contractnegotiationsandcontractrenewals. 

5. Ensuring appropriate dissemination of contract details to all applicable stakeholders. 

• Alwaysensurestheaccuracyandcompletenessofallprojects, information,andanalysis. 
• Support WHHS RCM and Compliance with price transparency efforts and initiatives. 

DemonstratesSkill

1. DirectandoverseeContract Managertoperformmodeling,financialimpacts,utilizingFinancialPlanningandAnalysisdata basedonaproject-by-projectbasis. 

2. Developrecommendationsregardingratesandcontractlanguagefornewandrenewedcontracts. 

3. Administermanagedcarecontracts,aswellasdevelopandmonitortrackingandreportingmechanismstoensureappropriatereimbursementandadherencetocontractterms. 

4. WorkwithallrelevantWashingtonHospitalHealthcareSystem computersystemstogarnerneededinformationforfinancialmodeling,tracking,analysis,customerrelations,etc. 

5. Workwithinternaldepartments,particularlyUtilizationManagementandPatientFinancialServices,toproactivelypromotemanagedcareandtoensureappropriateworkingrelationshipbetweenWashington HospitalHealthcareSystemsandPayor/medicalgroups. 

6. StandinforChief Revenue Officerwhenneededatintra-hospitalandexternalhospitalmeetings. 

7.  Alwayscomplieswithestablisheddepartmentpoliciesandguidelinesindevelopingprojects,informationandanalysis. 

8. Consistentlychallengestheappropriatenessofassumptionsandformulasusedinthepreparationofallprojects,informationandanalysis. 

9. Consistentlymonitorsthemonthlymanagedcaredatafrominformationsystemsandtakesappropriatefollow-upactions. 

10.Providessound,effectiveadvicetomanagementtoassistthemin makingeffectivedecisionsregardingmanagedcareandstrategicissuessurroundingmanagedcare.

11. Alwaysexercisescareandaccuracyinconductingcollectionandanalysisstudies. 

12. Takesresourceful/creative approachincollectingdata,conductingresearch,developingmethodologyandderivingconclusionsandrecommendations.

Planning& 

Coordinating 

1. Resolveclaimsissueswithcontracted Payorsandmedicalgroups. 

2. Develop,monitorandperformtrainingforallpatientintakeWashington HospitalHealthcareSystememployeestoensurecorrectPayor/medicalgroupidentificationandtracking,andotherissuesinmanagedcare. 

3.  Design,conductandcoordinatemeetingswithphysicianofficemanagerstoprovidetraininginareasofmanaged care.

Professionalism 

1. Consistentlyprovidesclearandthoroughinformationinthepreparationofallprojects,information,andanalysis 

2. Alwaysdisplaysstudyfindingsinaclear,organizedformat,andprepareswrittencommunication/reports inaclear,conciseandorganizedfashion.

3. Consistentlymeetsscheduledtimeframesinpreparingallprojects,information,andanalysis. 

4.Consistentlyrespondstoinquiriesfrommanagementregardinginformationestablishedfromallprojectsandanalysis. 

5. Demonstratesgoodjudgmentwhencommunicatingwith patients/customersofvariousagegroupsbymodifyingdeliveryandcomplexityofinformationbasedonage.

 

 

ImprovingtheOrganization

1. Regularlyidentifiessystemenhancementopportunitiesandrecommendsappropriatechanges. 

2. Participatesinmultidisciplinary performanceimprovementactivities. 

3. Identifiesopportunitiesforimprovementinmanagedcarecontractingandrelationshipsthroughdirectinputfromaffecteddepartments, includingregistration,patientaccounting,billing,utilizationmanagement,medicalrecords,andqualityimprovement. 

4. Participatesinimprovingservicebyservingoncommitteesortaskforces,collectingdatawhenappropriate,andsharingideasforimprovement. 

5. ServesonProcessImprovementTeamsasrequested.

 

Self-Development

1. Attendsatleastoneeducationalprogrameachyear (i.e. HFMA, Becker’s or applicable other as approved by Chief of Payor Contracting).

RegulatoryCompliance 

1. Demonstratesawarenessof,andcompliancewith,patientsafety andregulatoryandlicensingstandards;i.e.,TJC,Title22,OSHA,HIPPAandWashington Hospital'snumberedmemorandums.

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