Network Director Managed Care

3 weeks ago

Valhalla, United States WMC Health Full time
Job Details:

Job Summary:

The Network Director Managed Care will report directly to the Network Vice President, Managed Care and will be responsible to lead the Managed Care Team in negotiating managed care contracts, including Pay for Performance arrangements, Centers of Excellence and overseeing all single case agreements (SCA's), and credentialing for the Network

Responsibilities:

  • Responsible for all Single Case Agreements (SCA's) on behalf of the Network, including updating SCA trackers.
  • Responsible to ensure all hospital, ancillary and delegated credentialing are completed timely for the Network.
  • Responsible for all Pay for Performance arrangements, this includes defining and implementing the metrics, monitoring of ongoing performance across the network, ensuring that payment of the metrics are on target to achieve maximum payment throughout the Network.
  • Responsible for Centers of Excellence with the managed care payers for the Network.
  • Minimizes administrative burdens by addressing issues timely with the managed care payers.
  • Participates in all managed care negotiations on behalf of the Network. This includes existing payers and first time payers.
  • Oversees review of managed care contract language, including redlining of contract language and rate exhibits for the Network.
  • Performs contracting modeling for negotiations.
  • Maintains and provides current payer rate grids including Hospital, Professional, Home Care and key language grids for the Network.
  • Works closely with revenue cycle and revenue integrity management to identify payer trends and resolves with the managed care payers.
  • Ability to efficiently and proactively manage staff, with a strong ability to communicate verbally and in writing.
  • Demonstrates strong project management skills.
  • Ability to multi-task on a daily basis.
  • Ability to assist with various reports as needed.
  • Other job duties as assigned.
Qualifications/Requirements:

Experience:

seven years finance/accounting experience, required. Healthcare finance experience preferred. Three to five years managing staff.

Education:

Bachelor's degree in Finance, Business Administration, Hospital Administration, or a closely related field, required. Master's degree, preferred.

Licenses / Certifications:

N/A

Other:

Special Requirements:
  • Thorough knowledge of various reimbursement methodologies, such as MSDRG, APR DRG, CPT-4, HCPCS, UB04 and NYS, CMS regulations as they relate to Managed Care Organizations.
  • Strong experience in review of managed care contract language, including red-lining of contracts and negotiating contracts for a healthcare setting.
  • Demonstrated proficiency in Microsoft Excel. Preferred experience with Access/SQL Databases, Cerner Millennium or other EMR/Billing systems.
  • Exhibits independent critical decision making within the scope of job duties
  • Displays critical thinking to proactively diagnose root cause of issues and develop solutions.
  • Has the ability to independently obtain, vet, analyze, and accurately summarize managed care agreements and data using all tools available.
  • Clearly and accurately, communicate data, report results, and other findings both in writing and verbally.

About Us:

NorthEast Provider Solutions Inc.

Benefits:
We offer a comprehensive compensation and benefits package which includes:
  • Health Insurance
  • Dental
  • Vision
  • Retirement Savings Plan
  • Flexible Saving Account
  • Paid Time Off
  • Holidays
  • Tuition Reimbursement

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