Credentialing

Nicklaus Children's Hospital•Miami, FL

About The Position

Responsible for technical and professional payer contracting and credentialing for the entire Health System. Provides guidance and support to Senior Leadership on payer contracting and negotiations, pricing, and delegated credentialing. Adapts the Health System to changes in the payer landscape and reimbursement structures, and leads and develops direct reports into a knowledgeable and effective team. Oversees in-network and out-of-network contracting and negotiations for the hospital and employed physician group, including out-of-network contracting for hospitals and employed physicians. Leads the Corporate Credentialing function and serves as the subject matter expert for current and historical payer contractual arrangements and issues. Works with leadership and departments across hospital and physician operations to resolve operational issues through negotiation, project planning, or contract modification. Builds payer and affiliate relationships, analyzes financial and payer performance information, supports contracting strategies, and leads payer Joint Operating Committee meetings. Ensures legal and regulatory compliance.

Requirements

Bachelor's degree in Business Administration or Health Management.
7–10 years of management experience in finance, analytics, or accounting in a health care-related field.
7–10 years of hospital or payer contracting and negotiation experience.
Demonstrated leadership progression.
Knowledge of governmental and commercial payer fee-for-volume and fee-for-value reimbursement methods.
Strong analytical skills and ability to interpret contract language.
Familiarity with working alongside lawyers and interpreting statutes and regulations.
Business acumen and strong financial skills.
Excellent written, oral, and communication skills.
Persuasion, influence, and negotiation skills.
Management expertise and strong knowledge of data analysis and statistics.
Ability to manage routine administrative work alongside changing, competing projects and urgent situations, sometimes simultaneously.
Ability to relate cooperatively and constructively with payers, coworkers, medical staff, executives, staff, elected officials, and managed care companies.
Clear, transparent communication style and ability to deliver difficult messages tactfully.
Ability to monitor and develop subordinates.
Ability to maintain confidentiality of sensitive information.
Knowledge of payer and hospital credentialing functions.
Ability to interpret, adapt, and react calmly under stressful conditions.
Ability to analyze and interpret complex models and apply them to business needs; strong spreadsheet skills.
Ability to use logical and scientific thinking to interpret technical data and solve a broad range of problems.
Independent, self-starting approach with sound judgment and time-management skills.
Ability to work under significant pressure while managing multiple priorities and maintaining focus and attention to detail.

Nice To Haves

MBA, MHA, and/or JD preferred.

Responsibilities

Maintain a detailed understanding of the health care industry, market dynamics, trends, competitors, regulations, and payer environment.
Collaborate with the management team and departments at all levels across hospital and physician operations.
Ensure operational issues are addressed and resolved through negotiation, project planning, or contract modification.
Create and maintain professional relationships with payers and potential affiliates.
Create, analyze, and interpret financial reports to support payer negotiations, trend analysis, and audits.
Implement and communicate contracting strategies in collaboration with a Senior Leader.
Manage out-of-network contracting for the hospital and employed physicians.
Manage and develop subordinates; provide direction, feedback, and recommendations on trended payer performance.
Serve as the subject matter expert for payer-related contractual arrangements and issues, both current and historical.
Oversee in-network and out-of-network contracting and negotiations for the hospital and employed physician group.
Make high-impact decisions requiring sound judgment.
Develop and lead Joint Operating Committee meetings with payers and relevant Health System departments.
Comply with legal and regulatory requirements.
Lead and oversee the Corporate Credentialing function.
Support new contracting strategies and approaches and contribute innovative ideas.