Director, Managed Care

Facility: WCO - Wellstar Corporate Office

Job Summary

This position oversees and directs the management of a defined scope of the system's managed care contracts and relationships with private payors potentially including managed Medicaid and Medicare Advantage payors. Overall, the managed care contracts represent a book of business in excess of $6B comprised of more than 150 contracts. They are responsible to implement strategic initiatives related to their assigned Managed Care contracts as set by Senior Vice President Managed Care and executive system leadership. They are responsible for managing, training and assisting the contract managers and managed care analyst team members on a day-to-day basis related to the specific payors. Significant partnership and interaction with revenue cycle function. Position ensures coordination and cooperation of managed care area with all applicable system departments including physicians, decision support, UM department, WCP, PFS, PAS and hospital personnel. Involved in developing managed care contracting strategy for new business ventures.

Core Responsibilities And Essential Functions

Oversee the negotiation and implementation of assigned managed care contracts for the System

• This includes the day-to-day responsibility of directly managing key managed care agreements and overseeing the remaining managed care agreements for any direct reports in the department.
• Participate in and lead rate negotiations and language negotiations for all assigned managed care payors for the department as appropriate.
• This includes training team members on reimbursement negotiation and contract language development and negotiation as needed. Manage day to day functions of Related to Assigned Payors
• Conduct joint operating committee meetings for assigned key payors and participate in all remaining joint operating committee meetings for the other assigned managed care payors.
• Participate and present as applicable in managed care team member and other system operational meetings for the department.
• Keep abreast of the current happenings with each assigned managed care payor and the managed care market as a whole. Evaluate and manage profitability of assigned managed care contracts individually and as a book of business
• Participate in the creation of an annual managed care budget which includes current inpatient and outpatient reimbursement and projected inpatient and outpatient reimbursement for each payor.
• Ensure all cost-of-living increases and charge master provisions for assigned payors are implemented timely and appropriately.
• Review revenue reports to understand contract performance as well as the implications of any contractual changes for assigned payors.
• Set annual contract renegotiation goals and identify revenue opportunities for the system for assigned payors.
• Ensure contract changes are communicated to all stakeholders and loaded in appropriate revenue cycle systems for assigned payors. Act as a liaison to other departments within the System to ensure compliance and revenue maximization with existing managed care contract terms for assigned payors.
• Represent managed care leadership and maintain constant contact with key departments within the system to ensure the managed care rates we have contracted have been paid by the payor. Some of these key departments include, PFS, CBO, PAS, WCP, Hospice, Home Health, Behavioral Health, and Cardiac Services.
• Represent managed care leadership and the department as a whole at various monthly or quarter meetings within the health system to discuss the managed care payors as appropriate and keep aware of issues that may arise with the payors (i.e. denials meeting, revenue cycle meeting, and managed Medicaid task force).
• Direct and develop the plan summaries for key assigned payors and oversee the plan summaries created by direct reports, which are distributed throughout the system and used by facility and physician team members. Oversee day to day network development and maintenance for specific products such as the WellStar Employee Plan, the IPA, the ACO and others as assigned.
• Work directly with any physicians group or hospital and assist the provider relations team that is working directly with a physician group or hospital to resolve an issue with an assigned managed care payor.
• Work collaboratively with AVP of managed care, Executive Director of CIN, ACO and WCP leadership and maintain constant contact with the provider relations team to ensure they are abreast of any reimbursement issues the physicians or hospitals have related to current or future assigned agreements and attempt to resolve them with current payors or address them with payors in future agreements.
• Oversee maintenance and communication of network participant demographics and designations for various plans and or products including ACO, WellStar Employee Plan and other managed care payors as assigned.
• Oversee and implement network designs for applicable products or plans such as the WellStar Employee Plan and the ACO as assigned.
  
  

Required Minimum Education

• Bachelors required. Masters preferre.d
  
  

Required Minimum Experience

• Minimum 10 years experience in healthcare or insurance industry is required.
• Minimum 8 years experience with Managed Care contract negotiations or Managed Care operations, plus experience directly managing and developing staff is required.
  
  

Required Minimum Skills

• Critical thinking skills
• Effective negotiation skills
• Ability to coach, mentor, and supervise management level staff
• Strong communication skills,
• Ability to resolve issues independently
• Ability to identify potential opportunities and threats to the system related to Managed Care contracts
• Ability to influence others