Director, Managed Care Contracting

Augusta Health•Fishersville, VA

About The Position

The Director of Managed Care Contracting develops and executes Augusta Health’s managed care contracting strategy across hospital, ancillary, and employed physician services. Reporting to the Senior Vice President & Chief Financial Officer, this role leads the full payer-contracting lifecycle, including strategy, financial modeling, rate and contract-language negotiations, implementation, and performance monitoring, with the goal of protecting and enhancing net revenue and supporting the long-term sustainability of the independent community health system. The Director personally leads negotiations with commercial and Medicare Advantage payers and serves as the primary liaison to external managed care consultants, advisors, and legal counsel. The role also develops and executes direct contracting for Augusta Health’s self-insured employee health plan, negotiating with hospitals, health systems, and providers frequently used by team members. In partnership with Finance, Revenue Cycle, Population Health, Human Resources, and clinical and operational leaders, the Director evaluates market trends and value-based payment opportunities, oversees contract analysis and financial modeling, ensures contract terms are implemented accurately, and monitors contract performance. The Director leads and develops the managed care contracting team and represents Augusta Health in relevant professional societies and industry forums.

Requirements

Seven years of progressive managed care contracting experience within a hospital, health system, or payer organization, emphasizing facility and professional contracting.
Three years of supervisory or management experience leading contracting, payer relations, or financial analysis staff.
Demonstrated success negotiating rates, terms, and contract language with major commercial and Medicare Advantage payers.
Experience developing and defending financial models and reimbursement analyses for payer negotiations.
Education in administration, finance, healthcare administration, economics, or a related field, or an equivalent combination of education and relevant managed care experience.
Driver’s license; to drive an Augusta Health vehicle, the employee must also be at least 21 and have a motor vehicle record approved by Risk Management.
Eligibility to work in the United States and meet Virginia state employment requirements.
Deep knowledge of managed care contracting, reimbursement methodologies—including DRG, per diem, fee schedule, percent-of-charge, capitation, and value-based models—and payer-provider dynamics.
Strong negotiation skills and the ability to lead complex rate and contract-language negotiations to successful outcomes.
Strong financial acumen and ability to direct contract modeling, rate analyses, and net revenue projections in partnership with Finance leadership.
Working knowledge of federal and state managed care regulations, including CMS requirements, Virginia insurance regulations, price transparency, and the No Surprises Act.
Ability to develop and communicate payer strategy recommendations to executive leadership using market trends and competitive intelligence.
Knowledge of self-insured employee health plan design, TPA and network arrangements, stop-loss coverage, and employer direct contracting strategies.
Ability to engage, direct, and evaluate external consultants and advisors and ensure their work aligns with organizational objectives.
Excellent communication, facilitation, and stakeholder-management skills, including the ability to influence at Board, C-suite, physician, and payer-executive levels.
Strong contract drafting and review skills, including attention to payment terms, escalators, carve-outs, termination, and dispute resolution.
Ability to resolve escalated payer issues involving payment variances, denials, authorizations, and credentialing in collaboration with Revenue Cycle.
Track record of building and developing high-performing analytical and contracting teams.
Collaborative, flexible leadership style with a service mentality and commitment to organizational culture.

Nice To Haves

Master’s degree (MBA, MHA, or equivalent) in business, healthcare administration, or a related field.
Formal training in negotiation, health law, or healthcare finance.
Certified Healthcare Financial Professional (CHFP) or Certified Revenue Cycle Representative (CRCR) credential through HFMA.
Certified Managed Care Executive or comparable managed care credential.
Membership in HFMA, ACHE, or comparable professional associations.
Experience in an independent community health system or similarly complex healthcare organization.
Experience with value-based care arrangements, including pay-for-performance, shared savings, shared risk, and bundled payment models.
Experience engaging and managing external managed care consultants, advisors, or legal counsel for negotiations.
Experience with self-insured employer health plans, third-party administrators, or employer direct contracting arrangements.
Both payer-side and provider-side contracting experience, with local or regional market knowledge.
Prior experience in a hospital, healthcare system, or related service-oriented environment.
Familiarity with Augusta Health’s systems, workflows, or organizational culture.

Responsibilities

Develop, recommend, and execute the enterprise managed care contracting strategy in alignment with Augusta Health’s strategic plan and financial objectives.
Monitor market trends, payer products, competitor positioning, and legislative and regulatory changes; use findings to inform recommendations to executive leadership.
Build and maintain productive relationships with commercial and Medicare Advantage payer representatives and executives.
Evaluate business opportunities, payer products, network participation decisions, and reimbursement structures for strategic and financial fit.
Prepare and present payer strategy updates, negotiation status reports, and contract performance summaries to the CFO and executive leadership.
Personally lead negotiations of rates, terms, and contract language for hospital, ancillary, and employed physician agreements with major payers.
Manage the negotiation lifecycle, including data preparation, financial modeling, proposal development, terms review, internal alignment, finalization, and implementation.
Negotiate contract language covering payment terms, escalators, policy incorporation, termination provisions, and dispute resolution.
Evaluate and negotiate value-based arrangements, including pay-for-performance, shared savings, and risk-based models, with Population Health and clinical leadership.
Establish negotiation timelines, priorities, and renewal calendars to prevent agreements from lapsing or auto-renewing on unfavorable terms.
Develop and execute direct contracting for Augusta Health’s self-insured employee health plan.
Analyze employee health plan claims, utilization, and network data with Human Resources and the plan’s TPA to identify high-volume external providers and potential savings.
Negotiate direct agreements with external providers and coordinate with the TPA on network configuration, claims administration, and repricing.
Partner with Human Resources, benefits consultants, and the TPA on plan design, steerage incentives, and team member communications supporting direct contracts.
Monitor direct-contract performance against medical plan cost targets and report realized savings to the CFO and executive leadership.
Serve as the primary liaison with external managed care consultants, advisors, and legal counsel supporting contracting activities.
Define consultant scopes of work, coordinate deliverables, and manage communications to ensure work meets organizational needs.
Integrate consultant analyses, benchmarking, and market intelligence into negotiation strategies and executive decision-making.
Evaluate consultant performance and value and recommend engagement scope, renewal, and selection to the CFO.
Coordinate consultants and internal stakeholders in preparing for and executing major payer negotiations and renegotiations.
Direct financial modeling and contract performance analysis to support negotiation strategy and organizational expectations.
Oversee what-if modeling of proposed rates, payment methodologies, and utilization scenarios to quantify net revenue impact.
Partner with the CFO, Finance leadership, and financial analysts to evaluate alternative payment methodologies.
Establish and monitor indicators for contract yield, payer mix, and expected-versus-actual reimbursement.
Support budgeting and forecasting with projected rate increases, payer mix shifts, and contract-driven net revenue changes.
Quantify and track the realized financial impact of negotiations against targets.
Ensure executed contract terms are accurately loaded, implemented, and communicated to Revenue Cycle, Patient Access, and other affected departments.
Monitor contract performance, identify payment variances and underperformance, and initiate corrective action with payers.
Oversee resolution of escalated payer issues involving payment promptness, denials, authorizations, credentialing, and payer-member concerns.
Maintain oversight of a centralized repository of executed agreements, amendments, rate exhibits, and key contract terms.
Maintain knowledge of applicable federal and state regulations, including CMS, Virginia Bureau of Insurance, price transparency, and No Surprises Act requirements, and ensure contracts remain compliant.
Interface with external and third-party auditors as requested and prepare for and defend contract questions and challenges.
Collaborate with Revenue Cycle, Population Health, Compliance, and clinical and operational leaders on payer policy changes and operational challenges.
Recruit, develop, and retain a high-performing managed care contracting team; organize team activities to meet deadlines and goals.
Supervise and train staff to maintain and improve the accuracy and timeliness of contract analyses and payer deliverables.
Foster a collaborative, results-oriented team culture that models Augusta Health’s values.
Represent Augusta Health in state and national professional societies, industry forums, and peer networks related to managed care and healthcare finance.

Benefits

Comprehensive medical, dental, and vision insurance coverage.
Retirement savings plans and financial wellness support programs.
Earned Wage Access Program for eligible team members.
Generous paid time off and flexible scheduling.
Career development programs, including clinical ladders, shared governance, and advancement opportunities.
Personalized onboarding with dedicated preceptors and ongoing educational support.
Tuition reimbursement.
Onsite childcare.
Free onsite parking.
24/7 armed security.
Health Fitness Reimbursement Program.
Onsite credit union and pharmacy.
Competitive pay with shift and weekend differentials.
Employee discounts at the cafeteria, gift shop, pharmacy, and local entertainment venues.