Strategic Director of Managed Care Contracting

1 week ago

Chicago, Illinois, United States CEDENT Full time
About the Role

CEDENT is seeking a highly skilled and experienced professional to fill the position of Senior Manager Payor Provider Contracting Managed Care. This is a full-time position that offers a challenging work environment and opportunities for growth.

Key Responsibilities
  • Develop and implement strategic plans for managed care network development, including negotiation of contracts with third-party payers and providers.
  • Oversee the negotiation of managed care contracts, including fee-for-service and value-based care agreements, to ensure optimal reimbursement rates and maximize utilization.
  • Lead and direct strategic activities associated with negotiating, implementing, and maintaining complex managed care contracts and relationships with third-party risk-bearing entities.
  • Manage the development and negotiation of risk contracts with third-party payers and providers, including financial risk terms and models.
  • Monitor and analyze performance of third-party payer agreements, including profitability, volume, and strategic initiatives.
  • Establish and maintain a system of reviewing and assessing changes in Federal and/or State regulations in regards to Managed Care contracts.
  • Achieve and maintain a full understanding of Medicare and/or Medicaid pricing reimbursement and structure for both payors and providers.
  • Partner closely with the Clients PBM/pharmacy contracting function to ensure seamless integration and optimal outcomes.
  • Negotiate complex managed care contracts to secure optimal reimbursement rates and maximize utilization.
  • Lead the implementation of managed care contracts with internal departments to develop and maintain systems to disseminate contract information.
  • Lead and manage the contract terms and commitments to assure all deliverables are adhered to and take proactive measures before key milestones are missed.
  • Monitor the implementation process for all third-party programs, while balancing client needs and company objectives to ensure a successful/positive implementation for both parties.
  • Work with corporate and field on any reimbursement issues, and bring exceptions or non-standard requests to the attention of senior management where appropriate.
  • Maintain communication regarding third-party participation, contract compliance, and any other operational issues or opportunities.
  • Manage the tracking, approval, administration, and post-implementation process of all managed care contracts throughout the contract life cycle.
  • Review Third-Party medical adherence Contracts to ensure operational requirements can be met and implemented.
  • Negotiate, analyze, and model current, proposed, and final pricing terms for payors in accordance with pricing standards.
  • Lead the development and implementation of an annual strategic plan for third-party payer contracting, including the continued development of opportunities and implementation of pricing strategies and contract language standards.
  • Manage negotiations for all ad-hoc individual case agreements in accordance with policies and standards.
  • Establish and maintain a system of reviewing and assessing changes in Federal and/or State regulations in regards to Managed Care contracts.
  • Monitor the technical links between the Third-Party Provider and data tracking systems to assure reported issues are properly captured, reported, prioritized, and managed to closure.
  • Oversee a Third-Party Governance Process, including periodic status calls, quarterly performance reviews, annual business planning, change order reviews, and Third-Party budgets/costs.
  • Conduct periodic meetings/calls with internal departments to address administration issues, and coordinate resolution with the Service Provider as required.
  • Train and provide ongoing education to personnel, customers, contractors, etc. on processes and procedures to address Payor-related issues, updates, and opportunities.
  • Manage and audit the loading and updates of pricing and reimbursement terms to ensure contract compliance and appropriate profit and reimbursement.
About Our Company

CEDENT is a leading provider of managed care services, and we are committed to delivering high-quality solutions to our clients. As a member of our team, you will have the opportunity to work with a talented and experienced group of professionals who are dedicated to excellence.

What We Offer
  • A challenging work environment with opportunities for growth and development.
  • A competitive salary and benefits package.
  • The opportunity to work with a talented and experienced team of professionals.
  • The chance to make a meaningful contribution to the success of our company.

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