Managed Care Contracting and Performance Advisor

Guidehouse•Los Angeles, CA

2d•$113,000 - $188,000

About The Position

The Managed Care Contracting and Performance Advisor manages the strategic 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. The Advisor serves as a subject matter expert in managed care reimbursement methodologies, contract language interpretation, payer negotiations, and contract compliance. The position drives initiatives to improve financial outcomes and payer relationships, and supports organizational growth, financial sustainability, and market expansion through managed care strategies.

Requirements

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

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 improvement, contract optimization, and renegotiation opportunities.
Perform financial modeling and reimbursement analyses to assess proposed rate changes, contract amendments, and new payer arrangements.
Evaluate contract language and reimbursement methodologies, payment policies, authorization requirements, carve-outs, and obligations for operational, financial, and compliance risks.
Develop business cases and executive-level recommendations to inform contract strategy.
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 data-supported counterproposals.
Communicate with payer representatives to resolve negotiation issues and facilitate contract execution, while building productive payer relationships.
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.
Liaise between internal stakeholders and payer organizations to address contract interpretation questions and post-implementation issues.
Establish and monitor contract performance indicators, including reimbursement accuracy, denial trends, payment timeliness, underpayments, and revenue yield.
Partner with Revenue Cycle leadership on contractual intent and operational compliance.
Investigate, escalate, and assist with resolving complex underpayment, denial, and reimbursement disputes.
Analyze payer performance trends and identify revenue recovery and contract compliance improvement opportunities.
Prepare executive 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 supporting organizational growth, financial sustainability, and market expansion.