Director Managed Care Contracting

MAJOR RESPONSIBILTIES

• Develop, evaluate, negotiate, implement, and communicate all aspects of a managed care or value added service contract, including but not limited to financial terms, operational responsibilities, delegation issues, utilization management, quality assurance program and credentialing process.
• Manage and assure integration and development of system strategies and contracting opportunities that may include shared savings, global/partial risk, fee-for-service and Accountable Care Organization.
• Identify opportunities for enhancing system wide understanding and support of the contracting process.
• Provide consultative support to Advocate senior management, Boards and various subcommittees.
• Serve as a key resource and develop contracting parameters (i.e. pricing, operations contract language, plan design) with Boards and subcommittees, PHO and medical group Directors, and Managed Care Contracting Committees.
• Serve as principal relationship manager, monitoring, maintaining and continually improving the relationships among managed care payers, sites, PHOs, product lines, medical groups, and vendors of value-added services.
• Develop contracting parameters with Boards and contracting committees, such as the Consolidated Finance Committee (CFC), and Operating Unit Managed Care Contracting Committee (OUM3C). Develop and present summary of contract provisions to these committees, and provide summaries as needed to the designated site directors for presentation to the facilities’ designated senior level management team.
• Assure correct loading of contracted provider network contract terms and facilitate implementation of HMO, PPO, POS, and other contracts with all departments, including finance, claims, customer service, medical management, and operations; and hospital patient accounts, admitting, registration, outpatient department and inpatient utilization management.
• Work with the contracted managed care payers to execute quality, revenue cycle targets, utilization, case management, credentialing programs and satisfaction surveys.
• Assure compliance with the Federal, State, HMO regulatory agencies, NCQA and/or similar accreditation requirements.
• Work with other Advocate Aurora departments to develop and implement system-wide programs related to managed care.
• Participate in the development of protocols, guidelines and special programs in order to improve interaction between and among Advocate and external entities. These may include initiatives to streamline administrative procedures, enhance revenue cycle operations, and improve physician support, among others.
• Conduct regular managed care seminars and/or in-services for medical staff and Advocate associates.
• Act as a resource for managed care questions and staff training for physicians and Advocate associates.
• Maintain communication with and provide assistance to operations, physicians, hospital departments, and contracted providers regarding medical and administrative procedures and processes.
• Act as a primary managed care liaison to system product line assignments.  Involvement in product development, managed care strategy.
• Act as a liaison to the Corporate Sales Staff for coordination of efforts as to managed care payers and contracting activities.
• Performs human resources responsibilities for staff which include interviewing and selection of new employees, promotions, staff development, performance evaluations, compensation changes, resolution of employee concerns, corrective actions, terminations, and overall employee morale.
• Recommends operating budgets, service area global financial risk budgets, and controls expenditures within approved budget objectives.
• Responsible for understanding and adhering to the organization's Code of Ethical Conduct and for ensuring that personal actions, and the actions of employees supervised, comply with the policies, regulations, and laws applicable to the organization's business.

MINIMUM EDUCATION AND EXPERIENCE REQUIRED

License/Registration/Certification Required:  None

Education Required:  Bachelor’s degree in financing or related field.

Experience Required: 7 years in marketing/operations/finance involved in managed care contracting.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

• Excellent contract negotiation skills.
• Thorough knowledge of hospital and physician (multi- specialty group, IPA or PHO) operations and services impacted by managed care. Thorough knowledge of the managed care industry.
• Knowledge of various reimbursement methodologies for both physicians and hospitals.
• Ability to develop computer financial models and pro-forma statements to determine viability of PHO compensation, payer rates, and value-added service vendor costs.
• Excellent written and verbal communication skills.
• Ability to navigate through clinical decision support system.
• Ability to use spreadsheet, presentation, and word processing software effectively.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.