Director, Managed Care

Guthrie Enterprise•Sayre, PA

1d•Onsite

About The Position

The Director, Managed Care is responsible for managed care contracting with health plans and related activities for The Guthrie Clinic under the direction of the Vice President, Managed Care. The position is located at The Guthrie Clinic corporate offices in Sayre, PA.

Requirements

Bachelor’s degree required, masters preferred in health care administration or related field required
A minimum of five (5) years of managed care contracting for a health system and/or health plan health plan, with experience in reimbursement analysis in either a provider or health plan

Responsibilities

Manage assigned portfolio of health plan contracts and relationships for all Guthrie hospitals, medical group, and ancillary providers.
Lead responsibility for negotiating smaller ‐ mid range non risk contracts ($0‐2 million net revenues) as assigned, providing support as directed for all other risk and non‐risk managed care contracts under the direction of Vice President, Managed Care, including negotiation of rates, payment methodologies, contract language, value based and shared /full risk payment programs. Also following all internal controls for contract review, approval and signature and in alignment with Guthrie’s vision, goals and objectives.
Perform revenue recovery audits in collaboration with revenue cycle and finance staff to identify and collect under or over payments from health plans, using a focused, analytical approach designed to maximize recoveries and avoid future under or overpayments.
Ensure Guthrie providers and health plans comply with all contract provisions, via tracking of performance through a variety of means, including audit of current performance via claims review, reports, etc.
Supports managed care oversight of partial and full risk contracts, assist in the tracking of pay for performance and risk contracts, with a focus on improved performance to budget, development and implementation of new reporting and tracking tools and collaboration with health plans and organizations of Guthrie.
Primary lead for implementation and ongoing management of completed contracts, including identification and tracking of critical contract and renewal dates, proper scanning, recording and filing of contract documents, dissemination and communication of information to internal constituents and education on new /revised terms.
Monitor contract performance regarding financial performance, payment integrity, value‐based payment programs, compliance with contract terms and key performance indicators. Monitoring health plan activity with respect to network development, product strategies, payment policies and other relevant market intelligence.
Liaison to assigned health plans and Guthrie departments and support areas such as patient access, billing offices and medical management areas to improve functions across departments with a focus on promoting proactive, professional and collaborative relationships, problem resolution and avoidance future of issues whenever possible.
Promote enhanced use of contract management and modeling tools to support contract negotiations, revenue recovery and contract performance; provides support to decision support, finance, and budget on managed care issues.
Prepare and provide training, materials, and tools for use by Guthrie providers and their staff regarding key managed care contract provisions, market trends and opportunities for improvement in support of facility goals and objectives, consistent with the mission and values of Guthrie. Proactively communicate and educate Guthrie operational areas regarding contract changes, policy updates, etc., to ensure Guthrie staff has information needed to successfully implement and operationalize agreements.
Manage all contract loading and review in Meditract, on the shared drives and in contract binders.
Perform other duties as assigned/required by supervisor.