Job Description – Director of Managed Care Contracting
Recommend and shape organizational position on various reimbursements and managed care contracting issues and represent the organization’s position to relevant constituents. Develop managed care contracting and revenue enhancement strategies with commercial insurance companies.
Develop managed care relationships with payers, physicians, employers, regulators, members, facility providers and government officials.
Develop briefings and programs on managed care strategies, relationship management and partnering.
Account management responsibilities for Contracted PPS Payors: ensuring PPS Payor contracts are effectively implemented and managed across the organization and that PPS Payor customers are effectively supported
Payor Contract Negotiation/Sales for Existing PPS Payor Contracts: responsible for ongoing sales/ negotiations with existing contracted payors including pricing negotiations, new product additions, new or existing coverage requirements, etc.
New Payor Contract Implementation: ensuring effective implementation of new payor contracts across PPS organization meeting all applicable payor requirements and driving optimal appropriate patient volume
PPS Payor Database Management/Maintenance: responsible for PPS Payor Database management and maintenance
Essential Job Duties:
Account Management: primary responsibility for ongoing contract PPS payor account management including optimizing appropriate patient set-up activity, ensuring coverage requirements are effectively communicated and understood by PPS functions, and all PPS information systems requiring payor contract-level information are effectively maintained
New Contract Implementation: ensuring effective implementation of new payor contracts across PPS organization meeting all applicable payor requirements and driving optimal appropriate patient volume
Credentialing/Re-credentialing of Contract Payors: responsible for the completion and submission of all contracted payor credentialing requests including new and existing contracted payors
Contract negotiations with Existing Contracted Payors: responsible for ongoing sales/ negotiations with existing contracted payors including pricing negotiations, new product additions, new or existing coverage requirements, etc.
Teaming with New Payor Contract Sales Function to drive overall PPS Payor Contract Objectives: work with Field Sales/New Payor Contracted Sales Reps to drive new payor contract sales meeting PPS objectives
Effectively Oversee and Manage Contract Coordinator Team: provide leadership and direction to Contract Coordinator team to meet department objectives
Monitoring Payor Requirements: monitoring payor correspondence, web sites, and provider manuals for ongoing changes to coverage requirements, pricing, and other changes. Ensure effective communication to organization of all changes and required maintenance updates to Payor Database, PPS billing systems, etc.
Monitoring Payor Market Trends: monitor payor market-level trends/strategies through all available sources and contacts. Provide strategic feedback to PPS leadership through on an ongoing basis
Member – PPS Pricing Committee: serve as member of PPS Pricing Committee. Prepare and present payor updates – pricing, coverage, and trending – as required. Ensure all negotiated payor contract pricing receives pricing committee approval if below defined standard pricing
Responsibility also includes maintaining payor fee schedules and working collaboratively on managed care claim issues with Field, Sales, RCM and Care Depts.
Working with Pricing Committee/Finance/Marketing to Ensure Contract Pricing Process meets PPS strategic requirements: work with the pricing leadership of the organization to define/implement standard contract product price minimums by HCPCS code
Partner with RCM to ensure implementation and maintenance of contract pricing/HCPCS coding in PPS billing system: manage process with RCM to ensure that pricing/HCPCS coding in PPS billing system meets contracted payor requirements. Working with RCM to troubleshoot/manage/resolve contracted payor billing and payment issues.
Partner with RCM to ensure that all re-contracting or new contract arrangements such as pricing, claims submission requirements, insurance verification requirements, adjustments claw back provisions, past timely filing limits, etc. can be managed within existing automated RCM billing systems and processing timelines prior to signing agreements.
Working with Field Operations/Sales/Peak Sleep to troubleshoot/manage/resolve contracted payor coverage and insurance verification issues: work with Field Operations/Sales/Peak Sleep/RCM to identify/troubleshoot/resolve patient onboarding, insurance verification, billing, and other payor issues as come up during the normal course of business
Manages the planning process for all contract renewals and negotiations including assessment of historical performance and issues. Prepares financial impact analysis/ modeling on new and revised contracts and maintains oversight tracking and yield determination.
Work with and assist the Compliance, RCM and Finance with special projects, which include the annual budget templates pertaining to managed care and market overviews.
Must be able to establish and maintain excellent relationships with Payors including contracting, medical director, and claims management employees and leadership
Strong knowledge of payor contracting processes, payor coverage requirements, payor insurance verification processes and payor billing and payment processes.
Strong knowledge of Medicare and Medicaid market including regulations and requirements. Includes knowledge of Managed Medicare and Managed Medicaid
Must be conversant with contract language and processes and ability to negotiate/review comprehensive contract language ensuring that PPS objectives are met and PPS interests are effectively protected
Excellent selling and negotiation skills
Good influence management skills and ability to work with all levels of internal and external customers
Project management skills
Excellent written and verbal skills
Excellent data analytics and reporting skills. Ability to manage data and team with Finance to work with organization to provide key reporting on payor performance
10 years + healthcare payor sales and contracting experience
BA/BS degree preferred
DME Contracting experience preferred
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