Managed Care Resource

1 week ago

Nashville, TN, United States Ensign Services Full time
About the Company

ESI currently serves over 350 health care operations that employ over 48,000 employees across 14 states. These operations have no corporate headquarters or traditional management hierarchy. Instead, they operate independently with support from the "Service Center" - a team of accounting, legal, human resources, benefits, compliance, payroll, construction, training and information technology resources. Service Center human resources employees are dedicated subject matter consultants who guide and advise field personnel. This structure allows on-site leaders and caregivers to focus on day-to-day issues in their individual operations. What sets ESI apart from other companies is the quality of our most valuable resource - our people.

About the Opportunity

The Managed Care Consultant supports the Skilled Nursing Facility leaders in managed care contracting and revenue enhancement strategies for all healthcare payers and preparation for changes in the healthcare industry. The Consultant will provide guidance regarding development of managed care relationships and rate negotiation, ensuring timeliness and rate appropriateness.

Additionally, the Consultant will negotiate contracts for new locations, assist with ensuring that contracts are updated for new services and help with contract cancellations, denials and appeals.

Essential Functions and Responsibilities
  • Establish, implement and evaluate the strategic plan(s) that will ensure each local operation the ability to optimize financial performance through rates and increased census.
  • Engage in complex levels of contract development and negotiation, including risk agreements using utilization, claims and market data with health plans and direct service agreements with physicians, physician organizations and hospitals and ancillary providers.
  • Identify, develop and maintain an effective relationship with contracted health plans and managed care regulatory agencies.
  • Manage complex and high-profile health plan negotiations. Actively draft and negotiate contracts in the health care operations and health care plan functional areas.
  • Assist in analysis and coordination of amendments, reimbursement, and language changes.
  • Assess resource utilization, cost management and negotiate effectively.
  • Monitor industry changes, trends and events to proactively identify opportunities to increase market penetration and performance improvement.
  • Understands the competitive pricing levels in the local market and improves the company's cost position through unit costs strategies.
  • Strategizes for facility census growth and retention.
  • Teach, Train and Instruct facility level personnel on how to operationalize the contract.
  • Interact with facility personnel on utilization, clinical results and managed care census.
Qualifications:
  • Knowledge of managed care contracting language, requirements, and methods to support the development and maintenance of contract compliance, contract language review and contract analysis.
  • Must be knowledgeable about the managed care environment, including capitation, PPO, HMO, IPA, ACO and POS.
  • Knowledge of CPT-4, HCPCS, Revenue and ICD coding.
  • Expert in Skilled Nursing Managed care plans.
  • Experience in successful operationalizing managed care contracts in the skilled nursing environment.
  • Knowledge of contracts and contractual interpretations for payment and benefit issues.
  • Working knowledge of medical terminology, claims payment, contract negotiations, and problem resolution; ability to work collaboratively in a team setting.
  • Communicate effectively at all organizational levels and in situations requiring instructing, persuading, negotiating, consulting, and advising.
  • Ability to deal with responsibility with confidential matters. Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA).
  • Strong analytical mind, with problem solving skills, an aptitude for accuracy, and attention to detail.
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously.
  • Excellent verbal and written communication skills, as well as excellent critical thinking skills.
  • Computer savvy (Contract Logix, MS Word, MS Outlook & Excel).
  • Ability to be flexible, be readily adaptable, and work in a rapidly and constantly changing environment.
  • Present in facilities on a weekly basis, (currently as deemed appropriate).
Desired Qualifications
  • Must live in Texas, preferably in the Dallas/Ft. Worth, Texas area.
  • Preference for bachelor's degree in business administration, management or health care administration.
  • Willing to travel up to 80% of the time (as deemed appropriate)
  • Highly desire at least 2 years' experience with Managed Care contracting.


Additional Information

Wage Rate: Depending on Experience

Position Type: Full-time, exempt employee

Benefits: Medical, dental, vision, life & AD&D insurance plans, 401(k) with matching contribution, vacation, sick and holiday pay

Location: Candidate must reside in the Dallas/Ft. Worth, Texas area.

Ensign Services, Inc. is an Equal Opportunity Employer. Pre-employment criminal background screening required.

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