Title: Senior Manager Payor Provider Contracting Managed Care @ Chicago, IL
Terms of Hire: Full time.
Salary: $140,000–$148,000 / YR + Benefits
Job Description:
Provide strategic direction for and oversight of all managed care network development activities. Oversees negotiation of all managed care contracting activities, both fee-for-service (FFS) and value based care (VBC) agreements. Responsible for leading and directing strategic activities associated with negotiating, implementing, and maintaining complex managed care contracts and relationships with third party risk bearing entities (i.e. payers and providers). This individual will work within an evolving business line of Clients focused on managed care services to coordinate contract negotiation, implementation, and administration for Client’s new healthcare services and solutions. This individual will also be responsible for ensuring that policies and procedures are revised and implemented to address any operational issues that are identified. This individual has expertise in managed care contracts of healthcare services, and their respective business issues and potential opportunities. This position shall also assist in Member education regarding payer agreements and in monitoring and enforcing payer compliance with contract terms. This position is pivotal to creating value for our partners/customers and growing and maximizing financial performance.
Job Responsibilities:
- Manages the development and negotiation of FFS & VBC risk contracts with third party payers & providers.
- Manages the negotiation of VBC financial risk terms working in conjunction with Analytics and actuary, when needed, to develop financial risk models to analyze payer VBC proposals including ACO, shared savings/shared risk, capitation, global bundled pricing and % of premium contracts.
- Monitor and analyze performance of third party payer agreements including profitability, volume, strategic initiatives and payer/provider compliance issues.
- Establish and maintain a system of reviewing and assessing changes in the 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 & providers.
- Partner closely with Clients PBM/pharmacy contracting function.
- Partners with the management team to identify, develop, and implement appropriate approaches, processes, and tools that elevate the analytics group.
- Negotiates complex managed care contracts and securing optimal reimbursement rates that maximize utilization and increase value.
- Leads the implementation of managed care contracts with internal departments to develop and maintain systems to disseminate contract information.
- Leads and manages the contract terms and commitments to assure all deliverables are adhered to and take proactive measures before key milestones are missed.
- Monitors the implementation process for all third party programs, while balancing client needs and company objectives to ensure a successful/positive implementation for both parties.
- Works with corporate and field on any reimbursement issues, and brings exceptions or non-standard requests to the attention of senior management where appropriate.
- Maintains communication regarding third party participation, contract compliance, and any other operational issues or opportunities.
- Working collaboratively with Revenue Management and Information Services departments to address operations, utilization and reimbursement issues.
- Manages the tracking, approval, administration, and post-implementation process of all managed care contracts throughout the contract life cycle.
- Reviews 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.
- Leads 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.
- Monitors 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.
- Oversees a Third Party Governance Process including periodic status calls, quarterly performance reviews, annual business planning, change order reviews and Third Party budgets/ costs. Conducts periodic meetings/ calls with internal departments to address administration issues, and coordinates resolution with the Service Provider as required.
- Trains and provides ongoing education to personnel, customers, contractors, etc. on processes and procedures to address Payor related issues, updates, and opportunities. Works with appropriate internal and external parties to load and update new/existing location, market, and provider information.
- Manages and audits the loading and updates of pricing and reimbursement terms to ensure contract compliance and appropriate profit and reimbursement.
You Will Enjoy:
- An opportunity to be a part of a great culture, an awesome team, a challenging work environment, and some fun along the way!
- Apply today to learn more and be part of our Growth story.
All applications will be kept strictly confidential and once shortlisted, our team will be in touch with you for further discussions.
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