Position Title : Director, Managed Care Contracting Department : Financial Services Job Description :
General Description : The Director, Managed Care Contracting has responsibility for negotiating and managing managed care agreements on behalf of OU Health hospitals and physicians and with third party payers, including but not limited to Commercial, Medicare Advantage and Medicaid managed care payers.
Under the direction of the SVP, Managed Care, the Director, Managed Care Contracting will analyze, negotiate, and implement new and renegotiated managed care agreements for the OU Health system, and develop payor strategies to ensure optimal contracting and operational performance.
The Director, Managed Care Contracting will focus on increasing net revenue through favorable contracts that exceed costs to provide care, as well as on capturing maximum referral volume from each executed contract wherever feasible.
This position is also responsible for managing and facilitating the relationship with third party payers including Joint operating Committees (JOCs).
This position will also exemplify the OU Health mission, vision and values and acts in accordance with OU Health policies and procedures.
The following information provides an overview of the skills, qualities, and qualifications needed for this role.
Essential Responsibilities :
Responsibilities listed in this section are core to the position. Inability to perform these responsibilities with or without an accommodation may result in disqualification from the position.
- Negotiate and manage all managed care contracts with third party payers in consultation with OU Health key stakeholders.
- Supervise, coach and mentor Manager, Managed Care Contracting.
- Build and maintain positive ongoing relationships with all third-party payers with the objective of maximizing market share and revenues for OU Health hospitals and physicians.
- Work closely with SVP, Managed Care and senior leadership to devise payer strategies that align with organizational goals including market access and financial strength.
This includes evaluation and initiation of new managed care contract opportunities, business models and payers' relationships.
- Advance organization's contracting and reimbursement strategy through optimization of existing contracts and development of new reimbursement models and innovative alternative payment models (APM).
- Negotiate key legal terms working in conjunction with Director, Managed Care Analytics, when needed, to develop financial models to analyze payer proposals.
Assess risk exposure, potential upside and downside opportunities.
- Coordinate feedback and approval of contracts including financial risks and rewards from OU Health stakeholders.
- Negotiate contract language and performance terms. This includes legal, compliance, quality measures, reporting and data exchange requirements.
- Lead implementation and coordination of new contracts.
- Establish, facilitate and participate in Payer joint operating committee (JOC) meetings.
- Work closely with support departments to develop, communicate and disseminate orientation educational materials to inform and educate key stakeholders regarding contract and performance terms, reporting tools and resources and market trends.
- Develop and maintain contract summaries including performance targets and measures matrix, timelines, contract requirements and deadlines.
- Owner of Contract Information System and other tools.
- Monitor and manage payer compliance issues including rosters, assignment, reports, delivery dates, fees, audits.
- Monitor and analyze changes in payer programs and policies that may affect contract performance and initiate negotiations as warranted.
- Work with Manager, Managed Care to coordinate any credentialing / provider enrollment or request for information (RFI's) requirements for new contract and initiatives (renewals).
- Revenue Cycle support including negotiation of claims settlements and single case agreements (SCAs).
- Participate in and report to various governing bodies including the OU Health Finance and Audit committee; support for these meetings and assist with contract material preparation and presentation.
- Create strategic alliances with internal and external groups to maximize payer relations and contract performance.
- Supervise Manager, Managed Care Contracting Manager. Set objectives, review performance, conduct staff professional development, and provide guidance in accordance with department objectives, policies, and procedures.
Facilitate staff recruitment, retention, and onboarding / orientation.
Performs other duties as assigned.
Minimum Qualifications :
Education : Bachelor degree in Business, Finance, Health Care, Economics or related field is required. MBA, MHA or related Master’s degree preferred.
Experience : 5 to 7 years of progressive leadership experience required, including experience within an academic medical center, multi-hospital health system or managed care organization (MCO) company.
Demonstrated experience in healthcare analytics and medical economic modeling. Direct experience leading the negotiations and management of complex managed care contracts.
License(s) / Certification(s) / Registration(s) Required : None.
Knowledge, Skills and Abilities :
- Strong knowledge of hospital and physician reimbursement methodologies (i.e. DRG, per diem, fee schedule, APC).
- Working knowledge of billing / coding terminology (i.e. ICD-10, CPT, Revenue codes).
- Procedural knowledge of hospital and physician practice accounts receivable management.
- Strong industry knowledge of population health management activities, fee-for-service delivery models and payment innovation.
- Strong financial knowledge base related to all managed care reimbursement methodologies including the various fee-for-service structures and risk-based structures such as capitation, shared savings and alternative payment models.
- Ability to think critically and strategically, understand complex concepts and quantitative analyses, synthesis information and make correct judgments.
- Strong written and verbal communication skills.
- Strong analytical and financial skills.
- Adapts well to rapid change and multiple, demanding priorities.
- Focuses on team success and promotes collaboration efforts with others.
- Excellent time and project management skills.
- Ability to network internally and externally to build relationships, facilitate discussion and resolution.
- Microsoft Office Suite advanced proficiency, particularly MS Excel, Access and PowerPoint.
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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more.
We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.
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