Regional Director of Managed Care & Payor Relations | PAM Health Corporate & Voyages BH

PAM Health•Enola, PA

About The Position

The Regional Director of Managed Care is responsible for ensuring that PAM Health and its key facilities are included in important managed care plan networks within their respective markets. This role involves maintaining and developing relationships with targeted Payor sources, securing, maintaining, and renegotiating payor contracts to meet or exceed PAM Health's business and financial objectives. The Director develops the payor network (including Managed Medicare, Managed Medicaid, Exchange Health Plans, ACOs, Bundled Payments, and other Gain Sharing Programs) to create a geographically competitive, broadly accessible, stable referral and payment source that achieves objectives for unit cost performance and trend management. The position also evaluates and negotiates contracts in compliance with PAM Health requirements, reimbursement structure standards, and other key process controls. Responsibilities include providing contract-specific information to PAM Health facilities, Corporate and Regional Operations, including the business office, admissions, operations, and the central billing office (CBO). The role is also responsible for developing, managing, and maintaining Payor summaries and ensuring the sharing of key Contract Rate Schedules with necessary partner organizations as Business Associates.

Requirements

College Degree Preferred
5 years Plus experience in either a Network Role within a Managed Care Health Plan or Public Payor Program, or Provider Experience in Managed Care Contracting Role.
Managed Care Certifications a plus
Attention to financial details a must
Effective written communications
Effective communicator
Entrepreneurial mindset to grow revenues and seek opportunities for positive increases in margins

Responsibilities

Serve as a strategic, educational, and support resource to District/Regional teams and corresponding care centers for Managed Care/Payor contracts and initiatives.
Manage all Managed Care contracting responsibilities for Voyages Behavioral Health Psychiatric Hospitals, including Inpatient (I/P) and Outpatient (O/P) programs, and the Spravato Depression Outpatient program.
Maintain 'Smart Sheet Contract Summaries' for Voyages Health Plan agreements.
Establish and manage relationships with local, regional, and national managed care leadership.
Ensure colleagues in the Central Billing Office, Facility Admissions, and Case Management have immediate access to corresponding contacts for rates and terms.
In collaboration with the EVP of Admissions and the Vice President of Managed Care, identify and support the development and implementation of local opportunities through contracting, education, and strategic initiatives, including Public Payors for Psych Services.
Support Episode of Care Management and serve as a resource expert to facilities, regional teams, and Corp Finance.
Resolve escalated issues with payors related to payment or other systemic issues that are contractually based, in concert with the Central Billing Office.
Collaborate with CBO Leadership on escalated claim issues and requested contracts.
Report opportunities and threats related to Managed Care/Payors to the SVP of Managed Care.
Provide analytics on potential risks and recommendations to Consulate.
Provide Transparency Competitive Information to the SVP of Managed Care and Corporate Office.
Identify payors in specific districts for which contracts are needed and, in collaboration with the SVP of Managed Care, secure agreements and relations to maintain or increase utilization for Consulate.
Coordinate closely with Regional Operations Teams to achieve goals of admitting more Managed Care Patients at Preferred Compensation terms.
Assist and support the Central Billing Office team with escalated insurance payor issues and trends to help drive down days of sales outstanding (DSO).
Participate in the development and management of a disciplined contracting process.
Provide recommendations and feedback to ensure the contracting process stays current and meets business and financial objectives.
Stay current on payor, reimbursement, CMS, and other healthcare reform issues.
Oversee, manage, and negotiate all assigned managed care agreements.
Take on new facilities for IRF and LTACH as assigned by the SVP.
Provide leadership within the contracting team, managing priorities, standards, and work.
Develop a disciplined contracting process that meets or exceeds PAM Health’s business and financial objectives.
Develop relationships with key payors’ decision-makers for both contracting and referral management.
Understand payor strategy and identify opportunities and threats to PAM Health.
Communicate opportunities and threats to leadership.
Participate in strategies and plans to best position PAM Health with Payors.
Use pertinent data and facts to identify and solve problems related to managed care and payor contracts/strategy.
Prioritize and organize own work to meet deadlines.
Provide explanations and information to others on topics within area of expertise, including managed care, product information, contract requirements, Health Plan Portals, policy requirements impacting billing and operations related to contracts, and payor strategy.
Support centers with the Letter of Agreement process and negotiate rates when requested by facilities or regions.
Review existing and new contracts, complete Contract Summaries in a timely and thorough manner, and secure rate increases when warranted from Health Plans and Work Comp Carriers when assigned.
Identify solutions to non-standard requests and problems with respect to managed care contracts, payors, and billing issues.
Translate Managed Care concepts into practice and advise on Benefit issues in Health Exchanges and other Health Plan updates.
Work with the team on Provider Portal issues and the Tricare program and VA CCN programs.
Provide explanations and information to internal constituents on difficult issues.
Work in collaboration with supervisor, providing timely progress, opportunities, and threats.
Act as a facilitator with Health Plan contacts to support CBO Collection Efforts.
Stay abreast of Transparency regulations as well as Provider Directory requirements.
Seek out additional opportunities to contract additional PAM Health facilities with Major Health Plan Line of Business expansion to expand business relationships with certain health plans.
Identify Managed Care Scorecards that may exist and are used to profile PAM Health facilities, provide them to individual facilities, and advise on how they can improve around certain measures.
Perform other business-related duties as assigned.