Director, Managed Care

Washington Hospital•Fremont, CA

About The Position

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, and financial analyses of managed care contracts for the healthcare system, performing financial reporting and financial modeling for senior management strategic managed care decision- making, and overseeing all Payor relations and managed care denial follow-up and resolution activities for the health care system. In addition to performing the essential functions listed below, may also be assigned other duties as required.

Requirements

Bachelor's degree (minimum ten 10 years’ experience can be substituted for formal education).
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.
Experience in an administratively responsible position with significant intra-department work.
Demonstrated interpersonal skills.
Demonstrated skill in working with a large variety of people of various organizations and levels.
Knowledge of legal terminology, understanding of governmental and legislative regulations.
Previous experience in the areas of managed care/finance/or patient accounting.
Demonstrated ability to perform financial analysis, including managed care contracting financial modeling.
Computer Skills: Financial Modeling, Windows 2000, Excel, 2000, Work 2000, PowerPoint.
Must possess technical and professional skills and knowledge of finance, patient accounting functions and managed care.
Must possess strong interpersonal skills, be an effective public speaker and be comfortable in working with diverse groups of individuals.
Must be able to competently represent Washington Hospital at administrative functions.
Must be able to work independently and creatively.

Nice To Haves

Master's degree in health related field

Responsibilities

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.
Responsible for the initial reading and financial analysis of managed care contracts for content, administrative issues, and appropriate financial return.
Evaluate financial performance of existing contractual relationships and monitor performance of new contractual relationships. This includes production of financial impact reports on an ongoing basis by both Payor and medical group.
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.
Prepare historical and financial data to provide support for contract negotiations and contract renewals.
Ensuring appropriate dissemination of contract details to all applicable stakeholders.
Always ensures the accuracy and completeness of all projects, information, and analysis.
Support WHHS RCM and Compliance with price transparency efforts and initiatives.
Direct and oversee Contract Manager to perform modeling, financial impacts, utilizing Financial Planning and Analysis data based on a project-by-project basis.
Develop recommendations regarding rates and contract language for new and renewed contracts.
Administer managed care contracts, as well as develop and monitor tracking and reporting mechanisms to ensure appropriate reimbursement and adherence to contract terms.
Work with all relevant Washington Hospital Healthcare System computer systems to garner needed information for financial modeling, tracking, analysis, customer relations, etc.
Work with internal departments, particularly Utilization Management and Patient Financial Services, to proactively promote managed care and to ensure appropriate working relationship between Washington Hospital Healthcare Systems and Payor/medical groups.
Stand in for Chief Revenue Officer when needed at intra-hospital and external hospital meetings.
Always complies with established department policies and guidelines in developing projects, information and analysis.
Consistently challenges the appropriateness of assumptions and formulas used in the preparation of all projects, information and analysis.
Consistently monitors the monthly managed care data from information systems and takes appropriate follow-up actions.
Provides sound, effective advice to management to assist them in making effective decisions regarding managed care and strategic issues surrounding managed care.
Always exercises care and accuracy in conducting collection and analysis studies.
Takes resourceful/creative approach in collecting data, conducting research, developing methodology and deriving conclusions and recommendations.
Resolve claims issues with contracted Payors and medical groups.
Develop, monitor and perform training for all patient intake Washington Hospital Healthcare System employees to ensure correct Payor/medical group identification and tracking, and other issues in managed care.
Design, conduct and coordinate meetings with physician office managers to provide training in areas of managed care.
Consistently provides clear and thorough information in the preparation of all projects, information, and analysis.
Always displays study findings in a clear, organized format, and prepares written communication/reports in a clear, concise and organized fashion.
Consistently meets scheduled time frames in preparing all projects, information, and analysis.
Consistently responds to inquiries from management regarding information established from all projects and analysis.
Demonstrates good judgment when communicating with patients/customers of various age groups by modifying delivery and complexity of information based on age.
Regularly identifies system enhancement opportunities and recommends appropriate changes.
Participates in multidisciplinary performance improvement activities.
Identifies opportunities for improvement in managed care contracting and relationships through direct input from affected departments, including registration, patient accounting, billing, utilization management, medical records, and quality improvement.
Participates in improving service by serving on committees or task forces, collecting data when appropriate, and sharing ideas for improvement.
Serves on Process Improvement Teams as requested.
Attends at least one educational program each year (i.e. HFMA, Becker’s or applicable other as approved by Chief of Payor Contracting).
Demonstrates awareness of, and compliance with, patient safety and regulatory and licensing standards; i.e., TJC, Title 22, OSHA, HIPPA and Washington Hospital's numbered memorandums.