Director, Managed Care

Wellstar Health System

Aug 6

Applications are closed

Job
Full-time
Expert Level
Atlanta

Requirements

**Required Minimum Education**
Bachelors required. Masters preferred.
**Required Minimum Experience**
Minimum 10 years experience in healthcare or insurance industry is required.
Minimum 8 years experience with Managed Care contract negotiations or Managed Care operations, plus experience directly managing and developing staff is required.
**Required Minimum Skills**
Critical thinking skills
Effective negotiation skills
Ability to coach, mentor, and supervise management level staff
Strong communication skills
Ability to resolve issues independently
Ability to identify potential opportunities and threats to the system related to Managed Care contracts
Ability to influence others

Responsibilities

Oversee the negotiation and implementation of assigned managed care contracts for the System
This includes the day-to-day responsibility of directly managing key managed care agreements and overseeing the remaining managed care agreements for any direct reports in the department.
Participate in and lead rate negotiations and language negotiations for all assigned managed care payors for the department as appropriate.
This includes training team members on reimbursement negotiation and contract language development and negotiation as needed.
Manage day to day functions of Related to Assigned Payors
Conduct joint operating committee meetings for assigned key payors and participate in all remaining joint operating committee meetings for the other assigned managed care payors.
Participate and present as applicable in managed care team member and other system operational meetings for the department.
Keep abreast of the current happenings with each assigned managed care payor and the managed care market as a whole.
Evaluate and manage profitability of assigned managed care contracts individually and as a book of business
Participate in the creation of an annual managed care budget which includes current inpatient and outpatient reimbursement and projected inpatient and outpatient reimbursement for each payor.
Ensure all cost-of-living increases and charge master provisions for assigned payors are implemented timely and appropriately.
Review revenue reports to understand contract performance as well as the implications of any contractual changes for assigned payors.
Set annual contract renegotiation goals and identify revenue opportunities for the system for assigned payors.
Ensure contract changes are communicated to all stakeholders and loaded in appropriate revenue cycle systems for assigned payors.
Act as a liaison to other departments within the System to ensure compliance and revenue maximization with existing managed care contract terms for assigned payors.
Represent managed care leadership and maintain constant contact with key departments within the system to ensure the managed care rates we have contracted have been paid by the payor.
Some of these key departments include, PFS, CBO, PAS, WCP, Hospice, Home Health, Behavioral Health, and Cardiac Services.
Represent managed care leadership and the department as a whole at various monthly or quarter meetings within the health system to discuss the managed care payors as appropriate and keep aware of issues that may arise with the payors (i.e. denials meeting, revenue cycle meeting, and managed Medicaid task force).
Direct and develop the plan summaries for key assigned payors and oversee the plan summaries created by direct reports, which are distributed throughout the system and used by facility and physician team members.
Oversee day to day network development and maintenance for specific products such as the WellStar Employee Plan, the IPA, the ACO and others as assigned.
Work directly with any physicians group or hospital and assist the provider relations team that is working directly with a physician group or hospital to resolve an issue with an assigned managed care payor.
Work collaboratively with AVP of managed care, Executive Director of CIN, ACO and WCP leadership and maintain constant contact with the provider relations team to ensure they are abreast of any reimbursement issues the physicians or hospitals have related to current or future assigned agreements and attempt to resolve them with current payors or address them with payors in future agreements.
Oversee maintenance and communication of network participant demographics and designations for various plans and or products including ACO, WellStar Employee Plan and other managed care payors as assigned.
Oversee and implement network designs for applicable products or plans such as the WellStar Employee Plan and the ACO as assigned.

FAQs

What is the primary responsibility of the Director of Managed Care?

The primary responsibility of the Director of Managed Care is to oversee and direct the management of the system's managed care contracts and relationships with private payors, including managed Medicaid and Medicare Advantage payors, representing a book of business in excess of $6B.

What level of education is required for this position?

A Bachelor's degree is required, while a Master's degree is preferred.

How many years of experience in the healthcare or insurance industry are required for the role?

A minimum of 10 years of experience in the healthcare or insurance industry is required.

What specific experience is needed in managed care operations?

A minimum of 8 years of experience with Managed Care contract negotiations or Managed Care operations, along with experience directly managing and developing staff, is required.

What skills are essential for this position?

Essential skills include critical thinking, effective negotiation, the ability to coach and mentor management-level staff, strong communication skills, independent issue resolution, opportunity and threat identification, and the ability to influence others.

Is training provided for team members in this role?

Yes, the Director of Managed Care is responsible for training team members on reimbursement negotiation and contract language development as needed.

Will the Director engage with other departments in the healthcare system?

Yes, significant partnership and interaction with various departments, including revenue cycle, physicians, and other system personnel, are integral to the role.

What kind of managed care payors will the director be involved with?

The Director will be involved with private payors, managed Medicaid, and Medicare Advantage payors.

Will the Director oversee the negotiation of new managed care contracts?

Yes, the Director will oversee the negotiation and implementation of assigned managed care contracts for the system.

How is contract performance evaluated in this role?

Contract performance is evaluated through the review of revenue reports to understand contract performance and implications of any contractual changes for assigned payors.

Wellstar Health System

To enhance the health and well-being of every person we serve.

Science & Healthcare

Industry

10,001+

Employees

1993

Founded Year

Mission & Purpose

At Wellstar Health System, our mission is to enhance the health and well-being of every person we serve. Nationally ranked and locally recognized for our high-quality care, inclusive culture and world-class doctors and caregivers, Wellstar is one of the largest, most integrated healthcare systems in Georgia.