The Director of Managed Care is responsible for enhancing and maintaining managed care operations between the CHRISTUS providers (Acute Care Hospitals, Physicians and Ancillary providers) and managed care payors, including Medicaid and Medicare managed care plans. Additionally, this position is responsible for negotiating managed care contacts on behalf of a Region. This position is accountable to work with corporate and regional staff to ensure the accurate implementation, administration and ongoing monitoring of managed care contracts and corresponding processes and procedures at the facility and System level. This position will lead or participate as part of the System negotiating team for all state level contracts. A high degree of professionalism is required due to the interaction with both internal and external (health plans/payers) contacts.
Leads and/or assists in the strategic planning, analysis and negotiation of System and region specific managed care contracts on an as-needed basis under the guidance of the System Director or the Corporate VP Managed Care department.
Responsible as the managed care subject matter expert to the assigned region.
Develops and maintains relationships with staff of managed care plans in the regions or corporate level of the organizations.
Directs staff in investigating and resolving managed care reimbursement issues identified by PFS and/or payers, including root cause issues including fee schedule and reimbursement loading of contracts.
Directs appropriate managed care related education and training including roll out of new payor contracts and new products (e.g. Marketplace-Health Insurance Exchange products)
Assures that new contracts are rolled out in a timely, accurate manner.
Assists in payor/plan dispute resolution projects as appropriate.
Negotiates one-time Letters of Agreement and/or template for Regional use.
Responsible for distribution of managed care related information to hospitals, physician group leadership, ancillary leadership and regions.
Participates in operational meetings with applicable payors as part of the Corporate Managed Care department.
Participates as part of System negotiating team for system-wide or regional-level managed care contracts.
Knowledge of general Federal and applicable State regulatory environment related to managed care and participates in legislative advocacy activities as appropriate.
Maintains strict confidentiality.
Uses oral and written communication skills to effectively convey ideas in a clear, positive manner that is consistent with the CHRISTUS Mission.
Implements job responsibilities in a manner that is consistent with CHRISTUS Health Mission and Code of Ethics.
Works with other CHRISTUS Health departments to ensure accurate understanding of interconnectedness of corporate and facility systems/processes/directives.
Performs other related work as assigned or required.
BA in Business Administration or like degree required
Excellent written and oral communication skills
Excellent organizational skills
Excellent training skills
Ability to plan work schedule to meet essential deadlines and targets.
Possesses personal and professional values consistent with those of CHRISTUS Health
At least seven (7) years of experience in health care setting and/or payor organizations with experience in contracting, claims resolution, relationship development and staff education with a managed care company or acute care hospital company.
C. Licenses, Registrations, or Certifications:
At least five (5) years of experience managing staff.
CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.