Work for a major health system in a visible position leading managed care contract modeling and analytics in relation to negotiations with insurance payors.
Develops and maintains analytical tools, manages and trains staff, and uses data to provide recommendations on reimbursement methodology and rates for managed care contracts. Prepares financial analyses of current state, models the financial impact of potential reimbursement methods and rates, and determines the optimum structure and rates for proposals during negotiations with managed care organizations. Systematically plans and executes medium and long range activities to prepare for future contracting events. Responds to extremely urgent, mission-critical projects driven by contracting opportunities or issues. Responsibilities span all System owned, leased or managed entities.
•Directs a team of professionals to meet the objectives of the department, division and System including providing accurate and timely information, and creating sophisticated, valid models for managed care financial terms, and improving operational and financial results.
•Manages multiple, complex projects using all available resources, while exercising good judgment toward meeting goals and objectives.
•Understands and complies with HIPAA requirements for PHI security and disclosure.
•Maintains knowledge of trends and developments in the field via journals and related materials, attending seminars, conferences and vendor training sessions.
•Ensures that staff regularly reviews performance of managed care portfolio and contracted payers using budgeted and modeled performance as benchmarks and highlighting performance issues or problems with key stakeholders.
•Focuses on employee development by coaching and educating in areas including data integrity, reimbursement, coding/DRGs, Managed Care, Payment Reform, margins and other healthcare operations.
•Ensures that staff maintains detailed documentation of modeling criteria and results from modeling and analyses including making recommendations as needed during active negotiations.
•Maintains documentation of policies and procedures and manages departmental decisions and responses to priorities.
•Reviews and documents completed reports/projects and establishes review and QA processes to ensure accuracy in modeling and analysis.
•Leads team to develop and maintain fee schedules and rate documents, provide analysis of proposals, make recommendations for optimum rate structures and terms, and communicate current rates/fees to internal customers.
•Collaborates with infrastructure teams to determine appropriate data sources and data needed to support managed care analytics.
Education and Experience:
Bachelors Degree required, Advanced degree, MBA or MHA preferred. Five to ten years of experience working with Contract Modeling and Analysis with a large multi-Hospital system or Payor.