Director, Managed Care

washingtonhospital; Fremont (CA); On-site; USD 196,000 - 294,000; Full time

Job summary

Washington Hospital seeks a Director of Managed Care Contracting to lead contracting efforts across commercial, Medicare Advantage, Medi-Cal, and other payor relations. You will oversee financial analyses, reporting, and strategic negotiations to support WHHS and related entities.

The role requires strong modeling skills, leadership, and deep industry knowledge. The position reports to the Vice President & Chief Revenue Officer and involves cross-department collaboration, regulatory awareness,

Qualifications

• Bachelor's degree required; ten years’ experience may substitute formal education.
• Master’s degree in health-related field desirable.
• Minimum seven years in a Managed Care Contracting role within a health plan or hospital; five years in leading Payor Relations/Contracting staff.

Responsibilities

• Negotiate and manage managed care contracts; maintain strategic relationships.
• Conduct financial analysis and modeling of contracts for content and returns.
• Develop proposals based on WHHS strategies and growth objectives.
• Disseminate contract details to stakeholders and ensure accuracy of all projects and analyses.
• Support revenue cycle management and price transparency initiatives.

Skills

Contracting leadership

Financial modeling

Payor relations

Negotiation

Interpersonal skills

MS Excel

Public speaking

Education

Bachelor's degree

Master's degree in health-related field

Tools

Excel

PowerPoint

Financial modeling software

Job description

Salary Range: $196,000.00 - $294,000.00

Position Summary

The Director, Managed Care Contracting, contributes to WHHS’ growth and profitability by providing contracting expertise to existing and new contractual relationships; and providing subject matter expertise, guidance, and direction regarding Managed Care Contracts.This includes coordination of commercial, Medicare Advantage, Medi-Cal Managed Care, Value-Based, Medicare Shared Savings, and other third party managed care contracts and Payor relation activities for Washington Hospital, Washington Township Medical Foundation, and DEVCO entities (surgery centers and other ancillary entities).The Director will be responsible for overseeing administration,review,andfinancialanalysesofmanagedcarecontractsfor the healthcaresystem, performingfinancialreportingandfinancialmodelingforseniormanagementstrategicmanagedcaredecisionmaking, and overseeing all Payor relations and managed care denial follow-up and resolution activities for the health care system. Inadditiontoperformingtheessentialfunctionslistedbelow,mayalsobeassignedotherdutiesasrequired.

Statement of Accountability

Reports to: Vice President & Chief Revenue Officer

Qualifications

Education

Required: Bachelor'sdegree (minimum ten 10 years’ experience can be substituted for formal education).

Desirable: Master'sdegreeinhealthrelatedfield

Experience

• Minimum seven (7) years in a Managed Care Contracting capacity within a health plan or hospital; and at least the five (5) years of experience managing and mentoring Contract Manager or Payor Relations representatives.
• Experience in an administratively responsible position with significant intra-department work.
• Demonstrated interpersonal skills.
• Demonstrated skill in working with a large variety of people of various organizations and levels.
• Knowledge of legal terminology, understanding of government and legislative regulations.
• Previous experience in the areas of managed care/finance or patient accounting.
• Demonstrated ability to perform financial analysis, including managed care contracting financial modeling.
• Computer Skills: Financial Modeling, Windows2000, Excel 2000, Work2000, PowerPoint.

Skills and Abilities

Must possess technical and professional skills and knowledge of finance, patient accounting functions and managed care. Must possess strong interpersonal skills, be an effective public speaker and be comfortable in working with diverse groups of individuals. Must be able to competently represent Washington Hospital at administrative functions. Must be able to work independently and creatively.

Essential Job Responsibilities

• Responsible for negotiating Managed Care Contracts. This includes routine contracting activities, maintaining strategic relationships, evaluating contracts, and acting as an internal resource in interpreting contracts.
• Responsible for the initial reading and financial analysis of managed care contracts for content, administrative issues, and appropriate financial return.
• Evaluate financial performance of existing contractual relationships and monitor performance of new contractual relationships. This includes production of financial impact reports on an ongoing basis by both Payor and medical group.
• Working closely with Managed Care and Finance leadership to develop contract proposals based on WHHS’ defined strategies, goals and objectives.
• Working closely with WHHS Strategy to participate in Employer Direct contracting, contracting for new WHHS services, and other strategic growth initiatives that require managed care contracting support.
• Prepare historical and financial data to provide support for contract negotiations and contract renewals.
• Ensuring appropriate dissemination of contract details to all applicable stakeholders.
• Always ensure the accuracy and completeness of all projects, information, and analysis.
• Support WHHS RCM and Compliance with price transparency efforts and initiatives.

Demonstrates Skill

• 1. DirectandoverseeContract Managertoperformmodeling,financialimpacts,utilizingFinancialPlanningandAnalysisdata basedonaproject-by-projectbasis.
• 2. Developrecommendationsregardingratesandcontractlanguagefornewandrenewedcontracts.
• 3. Administermanagedcarecontracts,aswellasdevelopandmonitortrackingandreportingmechanismstoensureappropriatereimbursementandadherencetocontractterms.
• 4. WorkwithallrelevantWashingtonHospitalHealthcareSystem computersystemstogarnerneededinformationforfinancialmodeling,tracking,analysis,customerrelations,etc.
• 5. Workwithinternaldepartments,particularlyUtilizationManagementandPatientFinancialServices,toproactivelypromotemanagedcareandtoensureappropriateworkingrelationshipbetweenWashington HospitalHealthcareSystemsandPayor/medicalgroups.
• 6. StandinforChief Revenue Officerwhenneededatintra-hospitalandexternalhospitalmeetings.
• 7. Alwayscomplieswithestablisheddepartmentpoliciesandguidelinesindevelopingprojects,informationandanalysis.
• 8. Consistentlychallengestheappropriatenessofassumptionsandformulasusedinthepreparationofallprojects,informationandanalysis.
• 9. Consistentlymonitorsthemonthlymanagedcaredatafrominformationsystemsandtakesappropriatefollow-upactions.
• 10. Providessound,effectiveadvicetomanagementtoassistthemin makingeffectivedecisionsregardingmanagedcareandstrategic issuessurroundingmanagedcare.
• 11. Alwaysexercisescareandaccuracyinconductingcollectionandanalysisstudies.
• 12. Takesresourceful/creative approachincollectingdata,conductingresearch,developingmethodologyandderivingconclusionsandrecommendations.

Planning

Coordinating

• 1. Resolveclaimsissueswithcontracted Payorsandmedicalgroups.
• 2. Develop,monitorandperformtrainingforallpatientintakeWashington HospitalHealthcareSystememployeestoensurecorrectPayor/medicalgroupidentificationandtracking,andotherissuesinmanagedcare.
• 3. Design,conductandcoordinatemeetingswithphysicianoffice managers to provide training in areas of managed care.

Professionalism

• 1. Consistentlyprovidesclearandthoroughinformationinthepreparationofallprojects,information,andanalysis
• 2. Alwaysdisplaysstudyfindingsinaclear,organizedformat,andprepareswrittencommunication/reports inaclear,conciseandorganizedfashion.
• 3. Consistentlymeetsscheduledtimeframesinpreparingall projects,information,andanalysis.
• 4. Consistentlyrespondstoinquiriesfrommanagementregarding informationestablishedfromallprojectsandanalysis.
• 5. Demonstratesgoodjudgmentwhencommunicatingwith patients/customersofvariousagegroupsbymodifyingdeliveryandcomplexityofinformationbasedonage.

ImprovingtheOrganization

• 1. Regularlyidentifiessystemenhancementopportunitiesandrecommendsappropriatechanges.
• 2. Participatesinmultidisciplinary performanceimprovementactivities.
• 3. Identifiesopportunitiesforimprovementinmanagedcarecontractingandrelationshipsthroughdirectinputfromaffecteddepartments, includingregistration,patientaccounting,billing,utilizationmanagement,medicalrecords,andqualityimprovement.
• 4. Participatesinimprovingservicebyservingoncommitteesortaskforces,collectingdatawhenappropriate,andsharingideasforimprovement.
• 5. ServesonProcessImprovementTeamsasrequested.

Self-Development

• 1. Attendsatleastoneeducationalprogrameachyear (i.e. HFMA, Becker’s or applicable other as approved by Chief of Payor Contracting).

RegulatoryCompliance

• 1. Demonstratesawarenessof,andcompliancewith,patientsafety andregulatoryandlicensingstandards;i.e.,TJC,Title22,OSHA,HIPPAandWashington Hospital'snumberedmemorandums.