SENIOR DIRECTOR MANAGED CARE

Job Overview:

Director Managed Care is responsible for evaluating, negotiating, and securing financially and administratively favorable managed care contracts with new and existing health plans/managed care organizations on behalf of TriHealth. Additionally, this individual will participate in and support the development of managed care strategies with senior executives, leading to initiatives for TriHealth to adapt to address ongoing healthcare payment reforms and evolving payment methodologies, including - but not limited to - accountable care organizations (ACOs) and clinically integrated networks (CINs). The leader will foster professional relationships with payor executives and serve as a liaison between TriHealth and payors. This individual will also be responsible for representing the interests of TriHealth in discussions related to managed care and all aspects of the day-to-day operations of managed care, including the development and oversight of managed care staff. The ideal candidate is a highly valued partner within TriHealth, working collaboratively across the organization.

Job Requirements:

Bachelor's Degree business, healthcare administration, or related field (Required)
7 - 10 years experience Management in managed care environment, health insurance industry, or managed care Product development/negotiations (Required)
Payor relations 
Managed care ops 
Fee schedules 
Traditional, value-based, and innovative payment model terms and structures 
Payer denial management 
Maintaining, fostering and developing employer relationships 
Developing and monitoring payor scorecards 
Lead and direct JOCs 
Lead and support Population Health Initiatives 
Strategic alliances with internal customers 
Ability to work in collaboration with senior leaders, advising on strategic decisions 
Development and oversight of managed care team (recruiting/re-recruiting) 
Content expert for internal/external departments for all managed care terms and strategies

Job Responsibilities:

Leads Health System's participation with managed care plans, with responsibility for execution and delivery of new opportunities and proposals with respect to Health System's contracting strategy and contracting and financial standards o Serves as a leader of the managed care team, providing strategic direction on managed care related issues o Leads the development of the Health System’s managed care relationships, including establishment of clear and effective plans for growth, negotiation, reimbursement structure, contract renewal planning process, and contract implementation o Reviews and responds to new payor proposals in line with Health System managed care strategy o Serve as the lead contract negotiator with payors, including Commercial, Medicare Advantage, and Managed Medicaid o Achieves results in line with budgeted and forecasted performance and growth requirements as set forth by Health System leadership o Partners with Health System revenue cycle, clinical, and operational teams to identify impacts and implement new contracts/products o Supports the education of revenue cycle, billing, and coding staff on changes in contract terms, policies, and procedures o Evaluates existing and proposed payor contract language against best practice and evaluates impact of any new proposed contract language 
Guides efforts to meet Health System's payor contracting objectives. Partners and participates in activities of others throughout Health System as needed to achieve objectives o Stays current with emerging payor trends, new reimbursement methodologies, national regulatory issues, plan benefits, payor activity, products and delivery channels including health insurance exchanges, market competition, etc. o Identifies opportunities and takes action to build strategic relationships between managed care and other areas, teams, department, or organizations to help achieve business goals o Works effectively in a matrixed environment, integrating and aligning with revenue cycle, credentialing, and operations teams and maintaining positive relationships and utilizing effective problem-solving skills o Lead joint operating committees (JOC) with contracted payors on a regular basis to discuss operational and administrative issues and develop and enhance the relationships between the parties o Follows up and resolves problems related to payor contracting in a timely manner o Provides regular status updates to leadership on progress and unresolved issues. o Supports the creation of annual payor contract renewal cycle timeline to effectively plan for upcoming contract renewals 
Provides Oversight and management to managed care department. Performs other managed care related activities as needed o Oversees human resource management for managed care creating a culture of employee engagement. o Ensures appropriate structure and delegation of functions