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Become A Managed Care Director

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Working As A Managed Care Director

  • Communicating with Supervisors, Peers, or Subordinates
  • Making Decisions and Solving Problems
  • Establishing and Maintaining Interpersonal Relationships
  • Evaluating Information to Determine Compliance with Standards
  • Developing and Building Teams
  • Deal with People

  • Unpleasant/Angry People

  • Mostly Sitting

  • Make Decisions

  • $94,500

    Average Salary

What Does A Managed Care Director Do At Laboratory Corporation of America

* Articulate LabCorp's value proposition and communicates LabCorp's specialty testing offering, including genetics, pathology and esoteric testing to health plan contracting and medical teams.
* Secure coverage and reimbursement for new technology and focus tests.
* Work with health plans to improve coverage positions for specialty tests.
* Reviews and responds to proposals and contracts.
* Negotiates pricing, execution and implementation of the contracts for selected Managed Care accounts.
* Review Managed Care contracts from a financial and operational basis and work with division/regional business development, financial and contract administrators in order to represent all LabCorp's interests in contract negotiations
* Modifies existing contracts to appropriately reflect LabCorp's operational policies, procedures and capabilities.
* Responsible for models for pricing review.
* Initiate programs and processes to retain current business and grow the business in each contract, including maximizing pull through opportunities.
* Communicates to specialty testing group and LCA management on the performance of the division/region's Managed Care customers, including problems, concerns, and issues related to billing/customer service and reimbursement.
* Works with appropriate departments and managers to resolve issues.
* Analyzes and monitors fees for Managed Care customers.
* Includes utilization review and analysis for capitation rate adjustments for capitated plans.
* Ensures that regular price adjustments are implemented (with approval).
* Negotiate and implement pricing for years of coding, exclusions and new technology.
* Develops and implements Business Plan for Managed Care with a focus on profitable contracts with strategic significance for Division/Region an annual basis.
* Provides monthly update reports to management.
* Maintain regional Managed Care plan relationships focusing on regional "Anchor Plan" strategy.
* Responsible for relationships and communication with Managed Care plans.
* Periodic meetings with each plan are required.
* Quality reporting, Lab Leakage Initiatives, operational initiatives, demographic updates, new technology, etc. should be reviewed at joint operational meetings with customers.
* Verifies accounts are tracked in system appropriately and provides explanation of variations in accession volume and revenue.
* Keep informed of developments and trends relating to all areas of the company and MCO/PPO plans.
* Interact with all appropriate departments and sales personnel to ensure the proper handling and service of national accounts.
* Upsell accounts and address leakage through reports generated at LabCorp or from the plans.
* Attend sales meetings to provide training and templates as needed.
* Partner with sales team for client visits as needed.
* Works with specialty testing group billing supervisor to communicate contract specifics for new plans and changes in data requirements for existing plans to the field.
* Assists Contracts Administrator in conjunction with legal department on all contracts.
* Participates in Company assigned projects and attends required meetings.
* Maintains company required records and make reports on all phases of activities
* May be performed by MCAM, if available) Research, troubleshoot and resolve service issues related to national MCO/PPO accounts. (includes eligibility issues, report transmissions, specimen flow and TAT, demographic requirements, A/R issues, service issues, etc.) Monitor service and performance of accounts including billing, pricing, systems requests, payment activity, QA/QI reports, etc.
* May be performed by MCAM, if available) Work with Reimbursements Department and Billing Analysts to verify that fee schedules are reimbursed appropriately, rate changes are implemented and A/R issues are identified.
* When reimbursement or claims transmission and processing issues are identified, negotiate and track issues until successfully resolved.
* This job description reflects only the essential functions of the position and excludes those which may be incidental to the performance of the job.
* In no way it is stated or implied that the principal functions are the only duties to be performed.
* Employees will be required to follow any other job-related instructions and to perform any other job related duties requested by supervisor

What Does A Managed Care Director Do At HCA, Hospital Corporation of America

* Develops and implements departmental plans, including performance improvement activities and compliance with current regulations.
* Supervises and evaluates all personnel assigned to the unit and effectively utilizes nursing personnel, time responsibilities for the unit and is directly accountable to the Chief Nursing Officer.
* Communicates with staff, physicians and administration both written and verbally.
* Assumes house supervisory responsibilities as assigned, including responding to codes throughout the hospital, assessing and charting, and following through with appropriate documentation.
* Oversees the provision of patient care for the age groups listed below.
* Demonstrates knowledge of Patients Rights and the nursing performance.
* Evaluates nursing interventions, patient response, effectiveness, complications, communicates information to physicians and co-workers in a timely manner.
* Develops and implements policies and procedure that guide and support the provision of care.
* Coordinates staff meetings on a regular basis to ensure adequate communication to staff

What Does A Managed Care Director Do At Valley View Medical Center

* _
* Oversees and participates in the development, negotiation, implementation, monitoring and management of all assigned managed care agreements
* Evaluates and recommends financial parameters and reimbursement methodologies
* Implements new managed care programs in conjunction with faculty, staff and hospital/practice administration.
* Keeps staff apprised of developments in the managed care marketplace
* Directs and participates in financial analysis of revenue projections based on contractual rates with payers, adverse trends, terms and appropriate recommendations or conclusions
* Analyze and monitor financial aspects of existing managed care contracts.
* Utilize analysis for feedback on contract renewals, renegotiations or termination.
* Make recommendations regarding participation or non-participation with new or existing agreements
* Facilitates promotion of departmental programs to provider networks
* Develop and audit payer fee schedules based on negotiated reimbursement rates by contract and/or product line
* Maintain and distribute participation information by payer by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated
* Responsible for reviewing managed care legal contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies
* Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance initiatives
* Assembles information and prepares materials for presentation to committees, administrators and managed care networks
* Perform special projects as requested by the Vice President of Managed Care
* Liaison with physician practices, hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
* Initiate contact with Managed Care Plans to begin negotiation/re-negotiation process.
* Catalog and organize contracts along with helping maintain contracts data base and maintaining Managed Care data base
* Work with the IRM Analytics Group to establish negotiating position
* Coordinate with Revenue Cycle Groups to assure contract compliance and troubleshoot reimbursement issues
* Develop strategies to link payment to performance and quality of the practices
* Coordinate Physician contracting with hospital and ancillary agreements
* Minimum Qualifications (Experience, Education and Special Certifications…)_
* Bachelor’s degree
* Negotiating experience.
* Word/Excel skills.
* Clinical and medical technology knowledge.
* Work requires between 5
* years Physician Practice or Health Plan experience;
* Significant knowledge of contractual, administrative, health insurance and operational issues related to managed care organizations, physician groups, hospitals and health insurance benefit plan designs.
*

What Does A Managed Care Director Do At SUNY Downstate Medical Center

* Reporting to the Chief Nursing Officer, the Director of Care Management provides leadership and organizational oversight to the Integrated Department of Care Management.
* The position plans, directs, implements and monitors hospital-wide efforts to ensure appropriate level as of care and psychosocial interventions while serving as a liaison for the hospital with medical staff, hospital departments and services, regulatory and extra review agencies, third party payers, financial services and community health and welfare services and community health and welfare services.
* Coordinates programs among department and services that assess the appropriateness of care, appropriateness of admissions and continued hospitalizations, monitors length of stay, observation status utilization, delays in discharges or care, case mix index and other reimbursement/financial indicators in order to recommendation and implement hospital-wide improvement strategies.
* The Director also assists in patient facilitation through participation in daily bed management meetings and implementation of multi-disciplinary activities to improve quality of care.
* Participates in the development of effective hospital-wide Care Management strategies, ensuring compliance with external accrediting agencies and patient care review requirements including but not limited to JCAHO and IPRO.
* Ensures compliance regarding resource allocation, discharge planning and social work intervention processes in accordance with regulatory agencies including but not limited to DOH, TJC, CMS, IPRO, OMH and other local bodies of authority, and acts as a liaison for the same.
* Supervises the integration of the activities of the departments assigned so the objectives of the Care Management programs are accomplished.
* Provides mechanism for discharge planning via hospital-wide implementation of Care Management plan and updates high risk screening on an ongoing basis in order to capture the needs of the community.
* Accountable for achieving Hospital LOS targets and 30 days re-admission rates.
* Tracks and analyzes data generated through internal and external sources.
* Coordinates and participates in special multi-disciplinary projects with appropriate hospital staff.
* Collaborates with hospital administration in identifying areas of concern and improvement.
* Acts as a resource person for all hospital employees and medical staff regarding Care Management.
* Participates as a member of the multi-disciplinary team to accomplish DSRIP goals.
* Maintains up-to-date department operations policies and procedures.
* Demonstrates leadership skills for all personnel within departments including assessing potential problem or risks and addressing them.
* Supports and provides clear direction and priorities for staff within department to ensure high departmental productivity and functionality
* DUTIES AND RESPONSIBILITIES ARE NOT LIMITED TO THE ABOVE POSITION DESCRIPTION
* All successful candidates must undergo various background checks, maintain credentials required for continued employment and adhere to the SUNY
* DMC UHB Principles of Behavior.
* Clinical Faculty and Allied Health professionals must receive and maintain Medical Board authorization

What Does A Managed Care Director Do At Wheeler Clinic

* Ensures all care management clients have a comprehensive care management plan that is developed, monitored and evaluated by the team in a timely manner.
* All plans should meet clinical standards for chronic disease management and include social and psychological and quality of life factors.
* Provides clinical oversight and leadership to RN care management program activity across multiple Wheeler locations, serving adults by implementing, promoting and sustaining evidenced based and best practice models of chronic care management, patient outcome improvement, self-management goals, and nurse visits.
* Ensures all patient care transitions take place in a timely, effective and coordinated manner and that patient emergency room utilization is managed effectively.
* Provides consistent supervision and support to care managers, substance abuse care facilitation, and medication assisted treatment care managers to ensure goals are met consistently and timely for all program requirements.
* Works with VP of Health Center Operations, Care Managers, Medical Directors and Providers to ensure quality measures related to patient outcomes, screening recommendations, and development of nurse billable visit opportunities as all being met or exceeded.
* Assists with budget development and manages program expenses to budget, adhering to grant program budget requirements.
* Assists with grant program development with VP Health Center Operations and Chief Development Officer.
* Oversees Ryan White grant program requirements by ensuring timely reporting as required and outlined in the contract; establish and implement workflows aimed at improved patient outcomes as outlined in the grant contract.
* Ensures program compliance with accurate and timely weekly, monthly and/or quarterly data collection and submission requirements to sustain improved patient outcomes and compliance with screening recommendations.
* Comply with accreditation standards, required licenses, certifications, and program grant requirements.
* Serves as role model for supervisors, senior frontline staff, care managers and staff to promote strong work ethic and adherence to Wheeler Clinic Integrated Model of Care, Mission and Vision.
* Reviews care management cases, identifies training needs and other opportunities for improvement to ensure efficient and high-quality programming.
* Works with RN care managers to provide educational oversite and training for competency on nurse chronic care visits, and electronic health record use and function related to care planning, self-management goal setting and nurse documentation.
* In collaboration with the care management staff, identifies opportunities to streamline workflows that result in accurate, high quality production standards and improved results in cost savings, or outcome measure improvement.
* In collaboration with Wheeler's IT Department, defines and develops advanced analytic capabilities that support population health and disease management strategies.
* In collaboration with Wheeler's IT Department, supports implementation of care management software/platform.
* Develops materials and presentations on Care Management for current customers and new business opportunities.
* Conducts contract negotiations and monitors renewal processes for care management contracts.
* Must be able to pass a respirator fit test at time of hire and on an annual basis.
* Develops effective working relationships with and provides high quality service for external and internal customers.
* Oversees and manages UDS and other quality measure compliance; participate in quality improvement activities and committees and Joint Commission, Patient Centered Medical Home, HRSA and Connecticut public health site visits and other accrediting body site visits and compliance standards.
* Conducts performance evaluations of care management staff when necessary.
* Continues to develop knowledge and understanding about the history, traditions, values, family systems, and artistic expression of groups served as well as uses appropriate methodological approaches, skills, and techniques that reflect an understanding of culture.
* Wheeler Clinic is an EO Employer
* M/F/Veteran/Disability.
* All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status, sexual orientation, gender identity, or any other protected class.
* Affirmative
* Action Equal Opportunity Employer._
* To apply please email: recruitment@wheelerclinic.org

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How To Become A Managed Care Director

Most medical and health services managers have at least a bachelor’s degree before entering the field. However, master’s degrees are common and sometimes preferred by employers. Educational requirements vary by facility.

Education

Medical and health services managers typically need at least a bachelor’s degree to enter the occupation. However, master’s degrees are common and sometimes preferred by employers. Graduate programs often last between 2 and 3 years and may include up to 1 year of supervised administrative experience in a hospital or healthcare consulting setting.

Prospective medical and health services managers typically have a degree in health administration, health management, nursing, public health administration, or business administration. Degrees that focus on both management and healthcare combine business-related courses with courses in medical terminology, hospital organization, and health information systems. For example, a degree in health administration or health information management often includes courses in health services management, accounting and budgeting, human resources administration, strategic planning, law and ethics, health economics, and health information systems.

Work Experience in a Related Occupation

Many employers require prospective medical and health services managers to have some work experience in either an administrative or a clinical role in a hospital or other healthcare facility. For example, nursing home administrators usually have years of experience working as a registered nurse.

Others may begin their careers as medical records and health information technicians, administrative assistants, or financial clerks within a healthcare office.

Important Qualities

Analytical skills. Medical and health services managers must understand and follow current regulations and adapt to new laws.

Communication skills. These managers must effectively communicate policies and procedures with other health professionals and ensure their staff’s compliance with new laws and regulations.

Detail oriented. Medical and health services managers must pay attention to detail. They might be required to organize and maintain scheduling and billing information for very large facilities, such as hospitals.

Interpersonal skills. Medical and health services managers discuss staffing problems and patient information with other professionals, such as physicians and health insurance representatives.

Leadership skills. These managers are often responsible for finding creative solutions to staffing or other administrative problems. They must hire, train, motivate, and lead staff.

Technical skills. Medical and health services managers must stay up to date with advances in healthcare technology and data analytics. For example, they may need to use coding and classification software and electronic health record (EHR) systems as their facility adopts these technologies.

Licenses, Certifications, and Registrations

All states require licensure for nursing home administrators; requirements vary by state. In most states, these administrators must have a bachelor’s degree, complete a state-approved training program, and pass a national licensing exam. Some states also require applicants to pass a state-specific exam; others may require applicants to have previous work experience in a healthcare facility. Some states also require licensure for administrators in assisted-living facilities. For information on specific state-by-state licensure requirements, visit the National Association of Long Term Care Administrator Boards.

A license is typically not required in other areas of medical and health services management. However, some positions may require applicants to have a registered nurse or social worker license.

Although certification is not required, some managers choose to become certified. Certification is available in many areas of practice. For example, the Professional Association of Health Care Office Management offers certification in medical management, the American Health Information Management Association offers health information management certification, and the American College of Health Care Administrators offers the Certified Nursing Home Administrator and Certified Assisted Living Administrator distinctions.

Advancement

Medical and health services managers advance by moving into higher paying positions with more responsibility. Some health information managers, for example, can advance to become responsible for the entire hospital’s information systems. Other managers may advance to top executive positions within the organization.

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Top Skills for A Managed Care Director

FinancialAnalysisContractComplianceMentalHealthProviderRelationsHospitalsProceduresCareManagementMedicaidMedicalRecordsHealthPlanCareContractsOversightHMOPharmacyDiseaseManagementContractNegotiationsCareOrganizationsUtilizationManagementIPACustomerService

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Top Managed Care Director Skills

  1. Financial Analysis
  2. Contract Compliance
  3. Mental Health
You can check out examples of real life uses of top skills on resumes here:
  • Conducted training programs in: contract compliance, customer service, and managed care pricing negotiations for six regional buildings.
  • Develop and manage mental health and chemical dependency Intensive Outpatient Programs.
  • Directed Third Party Billing, Provider Relations, Network Development, Quality Assurance and Compliance issues as Third Party Administrator.
  • Negotiated managed care contracts, adding over 400 hospitals, 200 surgery centers and over 20,000 physicians to provider network.
  • Established and implemented short and long range divisional goals, objectives, strategic plan, policies, and operating procedures.

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