Job SummaryThe Director of Managed Care Contracting plays a critical role in supporting Augusta Health's mission and advancing departmental goals through measurable performance indicators and service excellence. This position contributes to a collaborative, patient-centered environment and helps drive outcomes aligned with organizational priorities.
Reporting to the Senior Vice President & Chief Financial Officer (CFO), the Director of Managed Care Contracting is responsible for developing and executing Augusta Health's managed care contracting strategy across all hospital, ancillary, and employed physician services.
This leader will direct the full lifecycle of payer contracting - including strategy development, financial modeling, rate and contract language negotiations, implementation, and ongoing performance monitoring - to protect and enhance net revenue and support Augusta Health's long-term sustainability as an independent community health system.
The Director will personally lead negotiations with commercial and Medicare Advantage payers and will serve as the primary liaison with external managed care consultants and advisors, coordinating their work and ensuring it aligns with Augusta Health's strategic and financial objectives. The Director will also lead direct contracting on behalf of Augusta Health's self-insured employee health plan, negotiating agreements directly with hospitals and health systems frequently utilized by team members to reduce medical plan costs.
Working in close partnership with Finance, Revenue Cycle, Population Health, and clinical and operational leadership, the Director will monitor market trends, evaluate value-based payment opportunities, and ensure negotiated terms are implemented accurately and performing as expected.
Essential Job Duties- Managed Care Strategy & Payer Relations
- Develop, recommend, and execute Augusta Health's enterprise managed care contracting strategy in alignment with the strategic plan and financial objectives.
- Monitor market trends, payer product development, competitor positioning, and legislative and regulatory changes to inform strategy recommendations to executive leadership.
- Build and maintain productive working relationships with payer representatives and executives across commercial and Medicare Advantage plans.
- Evaluate new business opportunities, payer products, network participation decisions, and reimbursement structures for strategic and financial fit.
- Prepare and present payer strategy updates, negotiation status reports, and contract performance summaries to the CFO and executive leadership.
- Contract Negotiations
- Personally lead negotiations of rates, terms, and contract language for hospital, ancillary, and employed physician agreements with major payers.
- Manage the full negotiation lifecycle, including data preparation, financial modeling, proposal development, terms review, internal alignment, finalization, and implementation.
- Negotiate contract language protecting Augusta Health's interests with respect to payment terms, escalators, policy incorporation, termination provisions, and dispute resolution.
- Evaluate and negotiate value-based arrangements, including pay-for-performance, shared savings, and risk-based models, in partnership with Population Health and clinical leadership.
- Establish negotiation timelines, priorities, and renewal calendars to ensure no agreement lapses or auto-renews on unfavorable terms.
- Employee Health Plan Direct Contracting
- Develop and execute a direct contracting strategy for Augusta Health's self-insured employee health plan, negotiating agreements directly with hospitals, health systems, and providers frequently utilized by team members in place of reliance on TPA network contracting.
- Analyze employee health plan claims, utilization, and network data in partnership with Human Resources and the plan's TPA to identify high-volume external providers and quantify savings opportunities from direct agreements.
- Negotiate rates, terms, and contract language for direct agreements with external providers, and coordinate with the TPA on network configuration, claims administration, and repricing.
- Partner with Human Resources, benefits consultants, and the TPA on plan design, steerage incentives, and team member communication supporting direct contracts.
- Monitor the performance of direct contracts against medical plan cost targets and report realized savings to the CFO and executive leadership.
Consultant & External Advisor Liaison - Serve as Augusta Health's primary liaison with external managed care consultants, advisors, and legal counsel supporting contracting activities.
- Define scopes of work, coordinate deliverables, and manage day-to-day communication with consulting partners to ensure work products meet organizational needs.
- Integrate consultant analyses, benchmarking, and market intelligence into Augusta Health's negotiation strategies and executive decision-making.
- Evaluate consultant performance and value, and make recommendations to the CFO regarding engagement scope, renewal, and selection.
- Coordinate consultants and internal stakeholders in preparing for and executing major payer negotiations and renegotiations.
- Financial Analysis & Contract Modeling
- Direct the financial modeling and contract performance analysis process, ensuring analyses support negotiation strategy and reflect organizational expectations.
- Oversee what-if modeling of proposed rates, payment methodologies, and utilization scenarios to quantify net revenue impact.
- Partner with the CFO, Finance leadership, and financial analysts to evaluate the feasibility and impact of alternative payment methodologies.
- Establish and monitor key performance indicators for contract yield, payer mix, and expected-versus-actual reimbursement.
- Support budgeting and forecasting processes with projected rate increases, payer mix shifts, and contract-driven net revenue changes.
- Quantify and track the realized financial impact of completed negotiations, ensuring rigorous benefit tracking against negotiation targets.
- Contract Implementation & Performance Monitoring
- Ensure executed contract terms are accurately loaded, implemented, and communicated to Revenue Cycle, Patient Access, and other affected departments.
- Monitor contract performance on an ongoing basis, identify payment variances and underperformance, and initiate corrective action with payers.
- Oversee resolution of escalated payer issues involving payment promptness, denials, authorizations, credentialing, and payer-member concerns.
- Maintain oversight of a centralized repository of executed agreements, amendments, rate exhibits, and key contract terms.
- Regulatory Compliance & Collaboration
- Maintain current knowledge of federal and state regulations affecting managed care contracting, including CMS, Virginia Bureau of Insurance, price transparency, and No Surprises Act requirements, and ensure contracts remain compliant.
- Interface with external and third-party auditors as requested; prepare for and defend contract questions and challenges.
- Collaborate with Revenue Cycle, Population Health, Compliance, and clinical and operational leadership to address payer-imposed policy changes and operational challenges.
- Team Leadership & Culture
- Recruit, develop, and retain a high-performing managed care contracting team, and plan and organize team activities to ensure deadlines and goals are met.
- Supervise and train staff to improve and maintain the accuracy and timeliness of contract analyses and payer deliverables.
- Foster a collaborative, results-oriented team culture that models Augusta Health's values.
- Represent Augusta Health in state and national professional societies, industry forums, and peer networks related to managed care and healthcare finance.
Required Qualifications- Education: Administration, Finance, Healthcare Administration, Economics, or a related field; or an equivalent combination of education and relevant managed care experience
- Licensure/Certification: None
- Experience:
- Seven (7) years of progressive managed care contracting experience within a hospital, health system, or payer organization, with emphasis on facility and professional contracting.
- Three (3) years of supervisory or management experience leading contracting, payer relations, or financial analysis staff.
- Demonstrated track record of successfully negotiating rates, terms, and contract language with major commercial and Medicare Advantage payers.
- Experience developing and defending financial models and reimbursement analyses in support of payer negotiations.
- Driver's License: Yes
- To drive an Augusta Health Vehicle, must also be 21 years old and Motor Vehicle Record (MVR) must be approved by Risk Management.
- Eligibility to work in the United States and meet Virginia state employment requirements
Preferred Qualifications- Education:
- Master's degree (MBA, MHA, or equivalent) in business, healthcare administration, or a related field
- Formal training in negotiation, health law, or healthcare finance
- Licensure/Certification:
- Certified Healthcare Financial Professional (CHFP) or Certified Revenue Cycle Representative (CRCR) through HFMA
- Certified Managed Care Executive or comparable managed care credential
- Membership in HFMA, ACHE, or comparable professional associations
- Experience:
- Experience working within an independent community health system or similarly complex healthcare organization.
- Experience with value-based care arrangements, including pay-for-performance, shared savings, shared risk, and bundled payment models.
- Experience engaging and managing external managed care consultants, advisors, or legal counsel in support of negotiations.
- Experience with self-insured employer health plans, third-party administrators (TPAs), or employer direct contracting arrangements.
- Both payer-side and provider-side contracting experience, with local or regional market knowledge.
- Prior experience in a hospital, healthcare system, or related service-oriented environment
- Familiarity with Augusta Health's systems, workflows, or organizational culture is a plus
Competencies, Knowledge, Skills and Abilities- Deep knowledge of managed care contracting, reimbursement methodologies (DRG, per diem, fee schedule, percent-of-charge, capitation, and value-based models), and payer-provider dynamics.
- Strong negotiation skills with demonstrated ability to lead complex rate and contract language negotiations to successful outcomes.
- Strong financial acumen with the ability to direct contract modeling, rate analyses, and net revenue impact projections in partnership with finance leadership.
- Working knowledge of federal and state regulations affecting managed care, including CMS requirements, Virginia insurance regulations, price transparency, and the No Surprises Act.
- Ability to develop and articulate payer strategy recommendations to executive leadership based on market trends and competitive intelligence.
- Knowledge of self-insured employee health plan design, TPA and network arrangements, stop-loss coverage, and employer direct contracting strategies.
- Ability to effectively engage, direct, and evaluate the work of external consultants and ad
