Managed Care Manager - FT - Days - MHS

Corporate Level Manager

At Memorial, we are dedicated to improving the health, well-being and, most of all, quality of life for the people entrusted to our care. An unwavering commitment to our service vision is what makes the difference. It is the foundation of The Memorial Experience.

Corporate level manager responsible for deploying and contributing to strategic and tactical initiatives for negotiations with national and regional payors. Manages execution of contracting initiatives for integrated delivery system to drive positive financial trend and to achieve an appropriate market price point on behalf of health system's acute care, ancillary and professional providers. Responsible for securing negotiations of all contractual provisions, implementing appropriate financial reimbursement models, and supporting operations by collaborating with clinical and operational staff to preserve revenue and address payer imposed challenges. Implement strategic and tactical initiatives to achieve organization and department goals.

Responsibilities :

• Address all single-case negotiations with non-contracted payors in a timely manner.
• Respond to insurance industry activities, healthcare reform, payer strategies, emerging market demands and legislative considerations and changes to the managed care industry to maintain and competitive position.
• Contribute and coordinate negotiations of ancillary services in concert with the Director of Managed Care for large, complex major-payor negotiations occurring simultaneously.
• Enhance, estimate and preserve net revenues and build market share. Assist with related strategies and operations.
• Assure financial viability of contracts through financial analysis and forecasting in conjunction with Financial Analyst(s), contract negotiations and issue resolution.
• Interface with managed care plans on claim reconciliations, trended issues and operational projects. Determine root cause and seek resolution.
• Evaluate payor assessments of overpayments and effectively dispute or resolve for settlement.
• Execute and manage legal, financial and operational contract language negotiations in concert with the Director of Managed Care. Execute contracting strategies for Memorial Hospitals, MHS employed physicians, transplant programs, and ancillary services (ambulatory surgical services, skilled nursing facility, rehabilitation facility, home health, home infusion, urgent care centers, sleep lab and other components) of the fully integrated healthcare delivery system and it's joint-owned or joint-ventured entities for fee-for-service and value based arrangements (capitation, bundled payments, pay for performance, shared savings, shared risk and full risk agreements).
• Monitor and analyze financial performance, reports and models, quality metrics and cost savings for negotiations with national and regional payors.
• Escalate, monitor and manage operational issues from Managed Care Revenue Optimization, Accounts Receivable Management or Joint Operations for solution or potential dispute resolution.
• Advise and support optimal operational performance by collaborating with other departments and facility staff impacted by payer organizations policies for authorization, denials, discharge planning, pharmaceutical programs, etc. Communicate, coordinate and research to collect information to resolve issues.

Competencies :

Education and Certification Requirements :

Bachelors (Required)

Additional Job Information :

Complexity of Work : Requires critical and flexible thinking skills, decisive judgment and the ability to work with minimal supervision. Must be able to work in a fast paced, high energy environment while multitasking, working independently and delivering quality outcomes. Must have strong technical & financial skills, negotiating skills and knowledge of contract language (develop, draft and interpret) and reimbursement terms. Extensive Managed Care Industry knowledge and understanding of hospital and insurance industries. Ability to work collaboratively in a collegial environment with multiple stakeholders to achieve department and organization goals. Required Work Experience : 5 years contracting experience with 3 years contracting for hospital, professional services, ancillary facilities or specialty networks.

Working Conditions and Physical Requirements :

75 lbs Non-Patient = 0%

75 lbs Non-Patient = 0%

Shift : Primarily for office workers - not eligible for shift differential