Senior Manager Payor Provider Contracting Managed Care Specialist

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 and contracting activities.
  • Negotiate and oversee managed care contracting activities, including fee-for-service and value-based care agreements.
  • Lead and direct strategic activities associated with negotiating, implementing, and maintaining complex managed care contracts and relationships with third-party risk-bearing entities.
Key Performance Indicators
  • Manage the development and negotiation of fee-for-service and value-based risk contracts with third-party payers and providers.
  • Negotiate value-based 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/or state regulations related to managed care contracts.
  • Achieve and maintain a comprehensive understanding of Medicare and/or Medicaid pricing reimbursement and structure for both payers and providers.
  • Partner closely with the clients' pharmacy benefit management (PBM) and pharmacy contracting functions.
  • Negotiate complex managed care contracts to 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 to prevent key milestones from being 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.
  • 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.
  • Establish and maintain a system for reviewing and assessing changes in federal and/or state regulations related to managed care contracts.
  • Monitor the 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 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 services to our clients.

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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