Director, Managed Care Operations, Michigan (Onsite based in Detroit, MI)

This position will focus on the development and growth of strategic partnerships with community physicians, FQHCs and local Managed Medicaid Plans.

This position will also work on identifying, managing, and resolvingmanaged care operational issues as well as assisting in Managed Care contracting and negotiations.

This position will interact externally with local managed care payors, FQHCs, POs and internally with constituents, including but not limited to : other Managed Care Contracting team members;

Conifer for Revenue Cycle matters; USPI Managed Care; Market Operators and Finance team members; Legal; and Managed Care Finance.

This position will also lead the resolution of escalated managed care operational issues and identify areas for operational improvement and implement related programs.

Essential job responsibilities include :

• Lead a successful conversion of the Physician Organization (PO) that the DMC Medical Group providers are currently enrolled in.
• Work in collaboration with the DMC Medical Group Physicians and Leadership to optimize performance for key quality levers to maximize reimbursement opportunities under P4P programs.
• Where appropriate, strategize where DMC hospital-based providers (University Pediatricians or Wayne Health) might have value-based opportunities that could further quality initiatives and support cost reduction in the DMC Market.
• Lead and ensure DMC Medical Group maximizes funding opportunities under the BCBS PGIP program.
• Lead hospital P4P quality improvement initiatives to maximize quality incentive payments.
• Develop and expand relationships with FQHCs and community PCPs to establish care pathways with the DMC and DMC specialists.
• In coordination with other Tenet Managed Care team members, function as the DMC liaison for provider relations, particularly with local Managed Medicaid and Medicare Advantage payers, to establish and maximize strategic alignment.
• Partner with Conifer, Tenet Managed Care and DMC reimbursement team to enhance collections under our contracts.
• Develop strategies for collaboration between DMC Medical Group Physicians and FQHCs, POs, and local Managed Medicaid plans for targeted service line growth.
• In coordination with other Tenet Managed Care team members, coordinate collaborations with DMC and targeted national Michigan Medicaid payers to ensure DMC’s network prominence in the new Medicaid environment, including implementing RFP commitments with certain Michigan Medicaid payers.

Required :

• Bachelor’s degree.
• 5+ years of relevant experience.
• Strong organizational and communication skills and ability to successfully navigate and add value with a collaborative personality in a highly matrixed organization.
• Strong relationships with people in the industry.
• Ability to travel up to 10% required. Selected candidates will be required to pass Motor Vehicle Record check.

Preferred :

Masters or other advanced degree.

Tenet Healthcare complies with federal, state, and / or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date.

If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.

LI-JR1

• Lead and manage the department of managed care, including personnel oversight, performance management, and team development.
• Develop and execute strategic initiatives to optimize reimbursement, negotiate favorable payer contracts, and drive revenue growth.
• Analyze and evaluate reimbursement rates, identify trends, and develop strategies to improve financial performance.
• Collaborate with executive leadership, finance, and legal teams to negotiate and manage payer contracts, ensuring favorable terms and conditions.
• Stay informed about industry trends, healthcare policies, and regulatory changes that impact managed care operations.
• Monitor and evaluate payer performance, identifying areas for improvement and implementing corrective actions as needed.
• Oversee the analysis and reporting of key performance indicators, providing insights and recommendations to drive operational efficiency.
• Foster strong relationships with third-party payers, advocating for the organization's interests and resolving contractual disputes effectively.
• Bachelor's degree in healthcare administration, business, or a related field (Master's degree preferred).
• Minimum of 8 years of progressive experience in managed care, including contract negotiations, reimbursement analysis, and payer relations.
• Demonstrated leadership experience, with the ability to effectively manage and develop a team.
• In-depth knowledge of healthcare reimbursement methodologies, payer contracting, and regulatory requirements.
• Strong financial acumen and analytical skills, with the ability to interpret data, identify trends, and make strategic recommendations.
• Excellent negotiation and communication skills, with the ability to influence stakeholders and build collaborative relationships.
• Familiarity with healthcare policy, industry trends, and emerging models of care delivery.
• Proven ability to drive results, meet deadlines, and effectively manage multiple priorities in a fast-paced environment.
• Knowledge of compliance standards and regulations related to managed care operations.
30+ days ago