Manager of Managed Care
4 weeks ago
PURPOSE STATEMENT:
The Manager of Managed Care is responsible for assessing the managed care contracting needs of each assigned facility and managed care readiness for key healthcare initiatives. Provides support and guidance to facilities in the areas of managed care contracting, managed care relationships and developing an infrastructure to support managed care business, payor mix, and contract operations. Assists in the development of a Division’s managed care contracting initiatives to include preparing facilities for Value Based Contracting. Develops training materials and provides on-site support to facility staff, when needed. Evaluates reimbursement rates and reimbursement methodology to result in a positive impact to facility’s net revenue growth.
ESSENTIAL FUNCTIONS:
Assists facilities in managed care contracting and revenue enhancement strategies for their area.
Uses data to determine areas where rates can be potentially improved.
Review rates and renewal dates by payer and facility to ensure facilities are negotiating rates timely and that rate requests are appropriate. Owns negotiation, when appropriate.
Provides guidance to facilities regarding development of managed care relationships and rates.
Assists facilities with ensuring managed care contracts are acceptable according to organization’s required standards and is responsible for pre-screening managed care contract terms prior to uploading to contract system for legal review. Assists in execution and implementation of contract changes.
Negotiates contracts for startup facilities and facilities who change from a self-pay model to a more diversified business model to include managed care.
Provides guidance on payor-related documents and forms needed for network participation and advises on making changes to network status including but not limited to: services offered, locations, and participating products.
Assists facilities with issues with major payors such as contract disputes and denials.
Work with facilities to monitor the impact of specific managed care strategies and contracts. Evaluates opportunities to grow net revenue by contracting and/or terminating contracts with payors.
Assist business development staff to ensure volume growth with key payors and achieve a balanced payor mix.
Provide ongoing training to facility staff on-site or via regularly scheduled conference calls.
Works with Vice President of Managed Care to maintain current knowledge of managed care trends and changes and ensure facilities are prepared for changes and remain compliant.
Works with division leadership and Corporate UM/Intake/Business Office staff to ensure payer related challenges and opportunities are addressed collaboratively.
Works with facility to develop managed care pitch to secure expanded business.
Surveys managed care organization’s needs and assists in evaluating potential growth opportunities.
OTHER FUNCTIONS:
Performs other duties as assigned.
STANDARD EXPECTATIONS:
Complies with organizational policies, procedures, performance improvement initiatives and maintains organizational and industry policies regarding confidentiality.
Communicate clearly and effectively to person(s) receiving services and their family members, guests and other members of the health care team.
Develops constructive and cooperative working relationships with others and maintains them over time.
Encourages and builds mutual trust, respect and cooperation among team members.
Maintains regular and predictable attendance.
Excellent interpersonal skills and ability to work with payors / managed care organizations and forge long standing Payor-Provider relationships.
Knowledge of office administration procedures with the ability to operate most standard office equipment.
Ability to work professionally with sensitive, proprietary data & information while maintaining confidentiality.
Exercises sound and strategic judgment in responding to inquiries; understands when to route inquiries to next level.
Self-motivated with strong organizational skills and superior attention to detail.
Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes.
Capable of working within established policies, procedures and practices prescribed by the organization.
English sufficient to provide and receive instructions/directions.
EDUCATION/EXPERIENCE/SKILL REQUIREMENTS:
Bachelor’s degree in business or healthcare related field.
Minimum 5 years’ contract experience in a health care facility/system or managed care organization. Previous behavioral healthcare experience preferred.
Knowledge of laws, regulations and rules related to healthcare and managed care.
Knowledge of major payors, reimbursement, and value based contracting models.
Effective and accurate oral and written communication skills. Ability to communicate interdepartmentally to include Business Office, UM, Clinical, Finance Operations, Compliance, Legal, and Senior Leaders.
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