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Strategic Director of Managed Care Contracting

2 months ago

Chicago, Illinois, United States Cedent Consulting Full time
Job Summary

Cedent Consulting is seeking a highly skilled and experienced Strategic Director of Managed Care Contracting to join our team. As a key member of our organization, you will be responsible for providing strategic direction and oversight of all managed care network development activities.

Key Responsibilities
  • Develop and negotiate fee-for-service (FFS) and value-based care (VBC) contracts with third-party payers and providers.
  • Negotiate VBC financial risk terms in conjunction with analytics and actuary teams to develop financial risk models.
  • Monitor and analyze performance of third-party payer agreements, including profitability, volume, and strategic initiatives.
  • Establish and maintain a system for reviewing and assessing changes in federal and state regulations regarding managed care contracts.
  • Achieve and maintain a full understanding of Medicare and Medicaid pricing reimbursement and structure for both payers and providers.
  • Partner closely with clients' pharmacy benefit manager (PBM) and pharmacy contracting functions.
  • Work with the management team to identify, develop, and implement approaches, processes, and tools that elevate the analytics group.
  • Negotiate complex managed care contracts and secure optimal reimbursement rates that maximize utilization and increase value.
  • Lead the implementation of managed care contracts with internal departments to develop and maintain systems for disseminating contract information.
  • Lead and manage contract terms and commitments to ensure all deliverables are met and take proactive measures before key milestones are missed.
  • Monitor the implementation process for all third-party programs, balancing client needs and company objectives to ensure a successful implementation for both parties.
  • Work with corporate and field teams on reimbursement issues and bring exceptions or non-standard requests to the attention of senior management as needed.
  • Maintain communication regarding third-party participation, contract compliance, and operational issues or opportunities.
  • Collaborate with revenue management and information services departments to address operations, utilization, and reimbursement issues.
  • 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 payers 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.
  • Monitor technical links between third-party providers and data tracking systems to ensure 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 needed.
  • Train and provide ongoing education to personnel, customers, contractors, etc. on processes and procedures to address payer-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.
What You'll Enjoy
  • An opportunity to be part of a great culture and a challenging work environment.
  • A chance to work with a talented team and contribute to the growth and success of Cedent Consulting.