Managed Care Contracting and Performance Advisor

Guidehouse•Los Angeles, CA

About The Position

The Managed Care Contracting and Performance Advisor is responsible for strategic management, evaluation, negotiation, implementation, and ongoing performance monitoring of managed care contracts. The role partners with Finance, Revenue Cycle, Operations, Physician Services, and payer organizations to optimize reimbursement, mitigate contractual risk, improve operational performance, and maximize revenue opportunities across hospital and physician service lines. It serves as a subject matter expert in managed care reimbursement methodologies, contract language interpretation, payer negotiations, and contract compliance, while advancing initiatives that improve financial outcomes and payer relationships. The advisor reviews and audits existing contracts, conducts financial modeling and reimbursement analyses, evaluates contract terms and risks, develops negotiation recommendations, and supports negotiations with commercial and government-sponsored payers. The role coordinates implementation of new or amended agreements, prepares operational contract materials, supports payer configuration and billing implementation, and helps resolve interpretation and post-implementation issues. The position also monitors contract-performance indicators such as reimbursement accuracy, denial trends, payment timeliness, underpayments, and revenue yield; investigates reimbursement disputes; identifies revenue recovery and compliance opportunities; and prepares executive-level reports. It contributes to payer and physician-network opportunities, value-based and risk-based contracting, alternative payment models, and managed care strategies supporting organizational growth and financial sustainability. Success is measured by improved reimbursement rates and contract terms, successful implementation of agreements, fewer underpayments, denials, and payment variances, stronger compliance and operational effectiveness, positive financial impact, timely dispute resolution, and strong stakeholder and payer relationships.

Requirements

Bachelor's degree and a minimum of 6–8+ years of prior relevant experience, or an AA degree and 8–10+ years of prior relevant experience; relevant experience may substitute for formal education or an advanced degree.
Relevant experience in a healthcare provider or central business office environment, managed care, contracting, healthcare finance, payer relations, related healthcare administrative roles, or a revenue cycle outsourcing company.

Nice To Haves

Demonstrated experience negotiating managed care agreements with commercial and government-sponsored health plans.
Experience performing reimbursement analyses, financial modeling, and contract reviews.
Knowledge of hospital and physician reimbursement methodologies, including Medicare, Medicaid/Medi-Cal, DRG, APC, fee schedules, capitation, and value-based payment models.
Strong understanding of managed care contract language and reimbursement structures.
Advanced analytical and financial modeling skills.
Ability to interpret complex contractual and reimbursement provisions.
Negotiation, communication, and relationship-management skills.
Ability to work effectively across multiple departments and organizational levels.
Strong project management and organizational skills.
Proficiency in Microsoft Excel, PowerPoint, and healthcare financial analytics tools.

Responsibilities

Review and audit existing managed care contracts to identify reimbursement improvements, optimization opportunities, and renegotiation needs.
Perform financial modeling and reimbursement analyses for proposed rate changes, contract amendments, and new payer arrangements.
Evaluate contract language, reimbursement methodologies, payment policies, authorization requirements, carve-outs, obligations, and related operational, financial, and compliance risks.
Develop business cases and executive-level recommendations to support contract strategy decisions.
Develop and execute negotiation plans for commercial, Medicare Advantage, Managed Medicaid, and other managed care payers.
Support payer negotiations on rates, contract language, payment methodologies, revenue-protection provisions, and operational requirements.
Analyze payer proposals and prepare counterproposals supported by financial and operational data.
Maintain communication and productive relationships with payer representatives, resolve negotiation issues, and facilitate contract execution.
Coordinate implementation of new or amended managed care agreements with Finance, Revenue Cycle, Patient Access, Case Management, and Physician Services.
Develop and maintain contract summaries, reimbursement guides, and reference materials translating contract terms into operational requirements.
Support payer configuration, billing implementation, reimbursement validation, and operational education after contract execution.
Act as a liaison between internal stakeholders and payers to resolve contract-interpretation questions and post-implementation issues.
Establish and monitor performance indicators for reimbursement accuracy, denial trends, payment timeliness, underpayments, and revenue yield.
Partner with Revenue Cycle leadership to interpret contractual intent and support operational compliance with contract terms.
Investigate, escalate, and help resolve complex underpayment, denial, and reimbursement disputes.
Analyze payer performance trends and identify revenue-recovery and contract-compliance improvement opportunities.
Prepare executive-level reports and presentations on contract performance, negotiation progress, financial impact, and strategic recommendations.
Identify and evaluate payer, IPA, medical group, and physician contracting opportunities.
Support physician-network and medical-group contracting strategies to expand patient access and referral opportunities.
Assist with value-based care, risk-based contracting, and alternative payment model initiatives as appropriate.
Contribute to managed care strategies that support organizational growth, financial sustainability, and market expansion.