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Senior Director Managed Care

Falls Church, VA, USA | Inova Health System

  • Industry:
    Healthcare - Hospitals
  • Position Type:
  • Functions:
    General Management
    Biotech/R&D/Science
  • Experience:
    10-12 years
Job Description:
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Develops and maintains a network of relationships with third party payors. Incumbent will establish and maintain effective relationships with facility and system operational management, as well as Patient Financial Services. Supports the VP of Managed Care in defining on an ongoing basis how Inova will interact strategically with third party payers on all levels of fee-for service negotiation, engagement on value-based contract structures, bundled arrangement, insurer product development, etc. Reporting to the Vice President of Managed Care and Credentialing, the incumbent will lead the team responsible for contract negotiations with third party payer, as well as ensuring that there is efficient and effective interaction between the health system and the third party payers as it relates to claims payment, ensuring that the yield of each contract is maximized. Contracted services covered include acute care hospitals, ambulatory surgery facilities, radiology centers, urgent care centers, free-standing emergency departments, full-service outpatient sites (HealthPlexes) reference laboratories and physician practice sites. This role will also oversee Contract Modeling, Analysis & Reporting - analytic support during all phases of managed care contracting, including the development of complex models during negotiations and the ongoing analysis, and reporting of payor performance. Oversees Network Insurance Credentialing which includes the processing for credentialing practitioners, facilities and CVO clients and Medicare and Medicaid enrollment for both practitioner and group practices in accordance with the appropriate NCQA & JC standards, managed care payers to include delegation credentialing requirements/maintenance and all applicable state and federal regulations. 



Duties:



• Manages a team of contracting and credentialing professionals



• Directs day-to-day activities of credentialing and managed care contracting staff. Responsible of the hiring, evaluation and termination of staff.



• Leads and participates on various committees and task forces.



• Provides support to lead business relationship leader with health plans.



• Manages portfolio of $2+ billion of commercial revenue.



• Oversees the provider credentialing functions.



• Manages the strategic, tactical and negotiating phases of contract, with health plans services to health plans and value based payment arrangements.



• Develops and maintains the standard conditions and terms for contracts with health plans.



• Develops a system-wide strategy for pricing of services to health plans.



• Oversees hospital, healthcare services and physician contracting functions including selective payment arrangements for desired services or health plans.



• Oversees analytics and other quantitative revenue analysis that supports contracts strategy.



• Works closely with the Revenue Cycle function to monitor health plan payment and procedural compliance on a routine and ongoing basis.


• Participates in the managed care revenue forecasting process.



• Supports key service lines through strategic managed care initiatives and participation in the RFP process.



• Plans and directs routine and ad hoc reporting on area managed care market specifically and the state of the managed care industry generally.



• Predicts and drives change in an increasingly competitive market and in Payer contractual relationships that better position the organization, financially and competitively.



• Monitors and reports contract performance on a routine and ongoing basis.



• Manages large appeals and negotiate settlements. Establish and maintains effective relationships with facility and system operational management, as well as Patient Financial Services.



• Develops effective working relationships with finance, legal, hospital leadership, clinical department leadership.



• Provides Managed Care and contracting guidance and expertise to other areas of the organization.



• Recognizes revenue opportunities and develop a strategy to incorporate them into existing and future contracts.



• Develops the strategy to incorporate the delivery and reimbursement for new technologies into existing and future contracts.



• Keeps abreast of financial and managed care regulations impacting the market and the organization.



• Negotiates rates and terms for single case agreements with plans with which Inova does not participate.



• Prepares routine and ad hoc reporting on area managed care market specifically and the state of the managed care industry generally. Serves on various committees and task forces.



• Lead and oversee Value Based Contracting activities.



• Lead Direct to Employer Planning activities and negotiations.



• Develop the strategy, objectives, techniques, and tactics to achieve the strategic goals of the department.



• Through decision support and analysis, support health plan, network, and managed care contract strategy, development, operations, and analysis of performance.


• Develop market analysis in preparation for negotiations.



• Draft, review and negotiate all Payer contracts, including ones flexible enough to respond to an ever-changing market over multi-year agreements.



• Responsible for ensuring providers are credentialed, appointed, and privileged with health plans.



• Lead, manage and ensure that all credentialing specialists review applications, verify both individual and facility accreditation, maintain records of verification and work with auditors as needed.



• Ensure the resolution of Claim Holds, Clearinghouse rejections and denials related to credentialing & provider enrolment issues in a timely manner to avoid delays and loss revenue.



• Collaborates as the subject matter expert with external customers and internal customer operational teams defining and managing priorities to ensure all credentialing is met to maximum revenue and value to our customers; provider groups, patients, and referring providers.



• Identifies process improvements or other efficiencies to improving our credentialing processes. 



Additional Requirements:



Education:



Bachelor’s Degree years or 10 years related experience; Master’s Degree Preferred.



Experience:



Ten or more years' experience in a high performing hospital system or managed care environment with experience negotiating hospital/ancillary/physician agreements.



Skills:



Significant knowledge of health plan operations and hospital, ancillary and physician contracting.

Knowledge of current trends in health insurance and the managed care marketplace.

Working knowledge of government and commercial risk sharing programs.


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