Managed care director job description

The Director of Managed Care & Revenue Cycle Improvement is a highly analytical health care finance professional with experience in managed care contract negotiations, contract management system maintenance, account management and claims processing within the health insurance industry as well as industry reimbursement benchmarks. The Director of Managed Care & Revenue Cycle Improvement will be responsible for professional, ancillary and other specialized entities/service lines (i.e. CSH and Behavioral Health) as well as support acute hospital: contracting data integrity, material contract non-compliance resolution, effective underpayment vendor management/installation/communication, contract rate and gross pricing strategy development, contract negotiation, A/R contract management system oversight for Managed Care payers.

Negotiate contracts and subsequent rate amendments for RWJBH professional, ancillary and other specialized entities/services lines.

Will assist in analyzing and negotiating managed care contracts for acute hospital entities as needed.

Reviews and recommends managed care contract language and negotiates such language recommendations with health plans, and in accordance with legal provisions from office of General Counsel.

Provides financial analysis for professional, ancillary and other specialized entities/service lines and service lines relating to rate comparisons and industry benchmarks.

Is highly knowledgeable in contract structures, revenue cycle, and reimbursements/regulations for hospital services.
Prepares and leads comprehensive financial impact analyses on actual and proposed contracts. Maintains relationships with key managed care payers and resolves material contract compliance issues In working with RWJBH revenue cycle leadership and joint venture partner relationships, where appropriate, installs internal and external procedures to ensure revenue stream safety net is in place. Reviews results of such efforts and implements sustainable process improvement to prevent revenue leakage and enhance revenue optimization. Works closely with other Managed Care team members and other company site/service line specific to execute strategic initiatives: Defensible pricing strategies. Innovative contracting solutions. Funding rate levels and contract operations improvements. Maintains working knowledge of insurance market and payer product platforms. Comprehensive understanding of varied reimbursement methodologies including risk and shared savings. Demonstrates a deep understanding of coding, billing, claims processing and collections for all aspects of an integrated health system. Demonstrates strong skillset in statistical analysis. Prepares revenue forecasts for budgetary purposes for managed care payers. Collaborates with entity/service line leadership in evaluating new service offerings, including price setting, net revenue estimates, and notification to insurance payers. Oversees the build, review and maintenance of the Professional and Ancillary Contract Management Systems. Works closely with Revenue Cycle Management team members to ensure contractual adjudication is occurring and if not accurately; oversees Managed Care team members restructuring Contract Management as needed. Works closely with payers with Managed Care team members to identify and track all payer policy changes that have a financial material change for all RWJBH entities. Work with Revenue Cycle, Government Relations, internal Managed Care team as needed to remedy the contractual material financial impact. Oversight of delegated credentialing and support individual credentialing for both practitioners and organizational providers. Responsible to ensure RWJBH Inc Corporate Services maintains NCQA Credentialing Accreditation.
Performs other revenue cycle/contracting duties as deemed necessary by Manager.
Job Qualifications/Education/Training/Certification/Licensure
Must have a minimum of 8 years of managed care contracting management experience in responsible positions in health care contracting. Must have a minimum of three years experience managing employees. Must have advanced knowledge of healthcare, managed care systems, HMO marketplace and market trends. Contracting experience mandatory; financial analysis experience required. Well-developed negotiating skills required. Advanced knowledge of contract related activities including: negotiations, legal, regulatory, operational, finance, and relationship management. Epic Certified / Badged in Contract Management both Professional and Facility. Strong problem-solving skills Financial analysis skills and contracting regulatory skills strongly preferred Strong written communications skills Advanced Excel spreadsheet skills are required Ability to multi-task and manage multiple projects simultaneously is required Advanced communication and analytical skills required to develop positive working relationships both internally and externally BA education minimum requirement Be able to communicate effectively in person, over the phone and maintain professional written communication
Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
We offer a great work environment, competitive rates and excellent benefits, including:
Medical/Dental/Vision plans 401 (k) Vacation/Personal/Holiday/Sick Time Off Short & Long Term Disability Basic Life & Accidental Death Insurance Tuition Reimbursement Health Care/Dependent Care Flexible Spending Accounts

IT'S SIMPLE. You want to work in a healthcare setting where you are valued and appreciated - where you receive respect from your superiors and co-workers as well as the patients/residents you treat. You want to be challenged by your job without being overwhelmed by it. You want to play an instrumental role in helping a patient recover, sometimes against strong odds, and go home. What you want is Kindred Healthcare. Our mission is to promote healing, provide hope, preserve dignity and produce value for each patient, resident, family member, customer, employee and shareholder we serve. Join us!

Manages facility wound care program including standards of care and practice related to wound, ostomy, and continence patient care needs. Functions in the role of expert wound clinician, coordinator, educator, consultant, and researcher. In collaboration with the medical staff, monitors the clinical wound care of patients and provides clinical support and consultation to improve patient care and patient outcomes

Develops and implements the facility wound care program in conjunction with the national standardization process, to include patient care protocols, documentation tools, wound care formulary and WCC referral criteria.

Models excellence in nursing practice through the utilization of advanced wound care concepts in the areas of assessment, diagnosis, planning, implementation and evaluation of perceived, actual or potential problems that occur in a variety of patient populations.

Establishes standards of care, competencies, policies and procedures in quality, cost efficient and effective wound care for all clinical staff.

Critically analyzes current wound care research methods and results for utilization in the expansion and improvement of LTAC patient care and patient outcomes.

Collaborates with the multidisciplinary team using evidence based practice to integrate wound care into a comprehensive plan of care for the patient/family.

Serves as a consultant to facility staff and advocates with physicians; through training and support, enables clinical staff to effectively assess wounds, recommend appropriate protocols, and initiate plans of care.
Qualifications Qualifications:

Education: Degree from an accredited program leading to licensure as a Registered Nurse. Masters Degree preferred.

Licenses/Certification: Current state RN license. Professional certification WOCN, WCC or CWS, or obtain certification within 12 months of employment.

Experience: Five (5) years licensed professional nursing experience with previous wound care and management experience required.

Job: NursingPrimary Location: CA-Gardena-Kindred Hospital - South BayOrganization: 4548 - Kindred Hospital - South BayShift: Day

• Bachelor's Degree required Master's Degree desirable.
• Over 5-years of managed care or health plan experience.
• Strong understanding of Managed Care: IPA, ACA, ACO, PHO, MSO (HMO, PPO and Government programs).
• Strong understanding of hospital, physician and ancillary reimbursement methodologies.
• Strong working knowledge of computer spreadsheet programs and database programs such as Access, CRM Programs.
• Expertise in transactional healthcare matters.
• Substantial knowledge of health care fraud and abuse laws and regulations.
• Strong research and analytical skills.
• Ability to manage several matters at one time in a fast-paced environment.
• High degree of maturity and professionalism.
• Exceptional presentation, writing and communication skills.
• A servant-leader who thrives on providing excellent customer service in a high-energy and high-accountability environment and has experience leading and directing others.
• A disciplined and self-motivated professional with solid work habits.
• An all-around team player who views no task as too large or too small, and who is passionate about the organization, its mission and the people it serves.
• An active listener, who displays good judgment, inspires confidence and handles confidential matters with absolute discretion.
• A positive and energetic person with a great sense of humor and a strong desire to help others perform and grow.
• Proven leadership and interpersonal skills, with a strong team orientation.
• Professional demeanor and executive presence.
• Ability to give clear direction and produce consistently outstanding results.
• A culture leader who can model and teach our unique culture across the organization.

Scheduled Weekly Hours:

40

Work Shift:

Company:

Sonic Healthcare USA, Inc

Sonic Healthcare USA is an equal opportunity employer that celebrates diversity and is committed to an inclusive workplace for all employees. We prohibit discrimination and harassment of any kind based on race, color, sex, religion, age, national origin, disability, genetics, veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.