Executive Director - Managed Care Operations

About the role

The Director of Managed Care conducts and coordinates the functions involved in Managed Care operations and contracting activities at the System level. Monitors and updates the administrative staff on political, legal and regulatory trends with respect to managed care and vertical integration. Works with Medical Economics, Finance and Revenue Cycle to produce reports for the Executive Director concerning managed care contract modeling and contract performance. This position is responsible for managed care financial analysis and analyzing contract proposals. This position is responsible for the medical economics staff and operation. This position will work with the various Revenue Cycle components/departments to ensure negotiation of the most appropriate contract terms/structures, etc. This position will work as a liaison between with managed care payers and system to facilitate resolution of contractual and operational issues in order to enhance managed care contract performance.

Responsibilities

• Responsible for research, analysis and negotiation of contractual agreements.
• Attend meetings with representatives of Managed Care Organizations, gathering information on their market presence and future development.
• Cook up the review of managed care contract language to achieve optimal reimbursement for NGHS and to promote internal efficiencies among internal departments that are affected by said contracts.
• Perform service specific reviews of volume and pricing in an effort to maximize contract performance.
• Cook up the preparation for and attendance at regular negotiation meetings with contracting parties.
• Cook up the administration/management of contracts through NGHS system, ensuring the dissemination of appropriate contract information to necessary internal/external users.
• Responsible for producing accurate final original documents.
• Develop the Medicare Advantage strategic goals and objectives, including the community focus and contracting strategic plan.
• Support VP of Managed Care in new contracting initiatives such as pay for performance.
• Establish relationships and serve as operational contact point with all contracting parties.
• Maintain lines of communication with payer contracting staff throughout contract item.
• Coordinate meetings with payers where the need is related to joint operations.
• Work with VP and Senior Management to lead the departmental efforts for effective employer engagement in an effort to prepare NGHS for a future with potential employer direct contracting.
• Oversee the addition of new facilities, new physicians and new services to managed care contracts.
• Serve as a liaison between various NGHS departments and Managed Care Operations.
• Oversee response to calls and emails from NGHS departments.
• Improve overall Managed Care integration into the NGHS organization through communication.
• Serve as a liaison between various NGHS departments and Managed Care Operations.
• Oversee the development and monitoring of managed care contracts.
• Develop and evaluate reports regarding the managed care contract performance and payment variances.
• Oversee managed care payment variance review function.
• Manage and maintain annual schedule of terminations, renewals, escalators, etc.
• Analyze payment variance reports/trends.
• Coordinate activities related to contract rate development, modeling prediction, and other analyses as required to support NGHS Finance and Revenue Cycle.
• Manage and coordinate Medical Economics department.
• Act as the point of contact for Finance and Revenue Cycle concerning procedure pricing (CDM), contract rates and managed care contract performance.
• Cook up the coordination of report building for various departmental needs.
• Cook up the coordination of payer research relative to new technologies contemplated by NGHS.
• Cook up the coordination of information gathering and feedback with industry experts on managed care market environment and NGHS relative market position.

Qualifications

• Licensure or other certifications: None specified
• Education: Bachelors Degree
• Experience: Seven (7) years of managed care contracting and/or managed care finance experience
• Preferred Licensure or other certifications: None specified
• Preferred Education: None specified
• Preferred Experience: None specified

Skills

• Extensive knowledge of the Managed Care environment in Georgia or similar market
• Successful relationship building skills
• Strong organizational and planning skills
• Good written communication skills including email
• Excellent analytical skills through use of various spreadsheet software (i.e. Excel), querying software and/or contract management programs

Benefits

Physical Demands: Weight Lifted: Up to 20 lbs, Frequently 31-65% of time
Weight Carried: Up to 20 lbs, Frequently 31-65% of time
Vision: Moderate, Frequently 31-65% of time
Kneeling/Stooping/Bending: Occasionally 0-30%
Standing/Walking: Occasionally 0-30%
Pushing/Pulling: Occasionally 0-30%
Intensity of Work: Occasionally 0-30%

Pay

N/A

Schedule

N/A