The Director, Managed Care Contracting is responsible for negotiation and implementation of Children’s agreements with both commercial and government managed care payors. This leader is instrumental in formulating, developing, implementing, and evolving Children’s managed care pricing and contracting strategy. This includes hospital, professional, behavioral, ambulatory, ancillary, and tertiary services. The Director, Managed Care Contracting reports to the Vice President of Managed Care and leads a team of professional focused on managed care contracting and communications. The Director also serves as a connection between the Managed Care department and internal stakeholders, to ensure that Children’s interests are represented, and to help stakeholders understand the terms and conditions of managed care plancontracts. This role is open due to a planned internal promotion as a part of Children’s succession management process. It provides a great opportunity to join a growing organization and work with a high performing team.
- Identifies, targets, prioritizes, and implements strategies and tactics tocontract with managed care plans that:
- Bring volume or maintain enrollee access to Children’s hospitals and providers;
- Represent benefit plans with sufficient financial or non-financial incentives to “steer” enrollees to participating providers to Children’s;
- Incorporate contractual terms and financial rates acceptable to Children’s management and Board of Directors; and
- Represent acceptable levels of risk to Children’s and its providers.
- Oversees Payor Managers to negotiate and conclude managed care agreements in a timely manner, within thelanguage and rate parameters adopted by Children’s on behalf of its hospitals, the Marcus Autism Center, Children’s ambulatory care centers, and over 1,000 employed,leased, andcontracted professional providers, with commercial and governmental managed care plans. Such agreements may be established directly with a managed care plan or through a clinically integratednetwork, The Children’s CareNetwork(“TCCN”). Agreements will include:
- General hospital service agreements, which include acute pediatric care, specialized inpatient rehabilitation services, transplant services, and specialized orthopedic, neurosurgical, cardiovascular and hematology-oncology services;
- Ambulance services;
- Freestanding ambulatory surgery services;
- Urgent care;
- Autism services;
- Prosthetics & orthotics services; and
- Primary care, specialty, behavioral and dental professional services.
- Works closely with Performance Analytics, Revenue Cycle and Reimbursement to evaluate the financial feasibility of current contracted rates and proposed rates, including the impact of rate-related terms, and ultimately determines that any agreed upon payment rates fall within those that are acceptable to Children’s. In addition, systematically gathers market rate and rate-related information to assist Children’s to update and revise its payment strategies.
- Establishes and updates Children’s Transfer & Shared Services agreements between Children’s hospitals and other acute care hospitals in Georgia to memorialize a basis for payment of Medicaid services that meet Georgia Medicaid’s definition of a “shared service”.
- Oversees the execution of individual case negotiations (i.e., spot contracts) and negotiates payor financial settlements, when warranted.
- Functions as Children’s management leader to plan and direct activities of Payor Managers and other departmental staff, and coordinates with others within Children’s to resolve problems and concerns associated with managed care payor agreements.
- Coordinates Managed Care’s participation in GHA Managed Care Society, locally, and CHA managed care venues, nationally, to monitor local and national trends, and reports to the VP of Managed Care and Children’s leadership on leading edge contracting and pricing strategies for Children’s.
- Leads other Children’s Contracting committees and subcommittees as needed. Participates on internal Children’s committees requiring Managed Care representation as requested.
- Works with VP of Managed Care, other Children’s leaders, and leaders of TCCN to accomplish the overall managed care goals of Children’s.
- Responsible for all aspects of managing and leading a team including: interviewing, hiring, training, developing, directing work and processes, managing performance, recognizing, and rewarding employees.
- Minimum of 8years of managed care contracting experience, with a demonstrated progression of increasing responsibility.
- At least 5 years of experience leading a team of contracting professionals, preferably at the Director level.
- Significant experience negotiating, drafting, and implementing contracts for managed care plans, health systems, or government agency with the responsibility to purchase health care services, or oversight of managed care plans.
KNOWLEDGE SKILLS & ABILITIES*
- Deep expertise and well versed in hospital and physician managed care term and rate negotiations, contract review and strategic planning and pricing.
- Working knowledge of Georgia Medicaid regulations and procedures.
- Ability to partner constructively with hospital service line and physician leaders, as well as otherhealthcare practitioners.
- Strong management, organizational, interpersonal, communication, teaching and presentation skills.
- Strong problem solving, listening, staff development and time management skills.
- Bachelor’s Degree in business or a clinical health discipline such as nursing.
- Advanced degree such as MBA or MHA.
- Exposure to value based agreements and implementation.
- Experience with transplant or other packaged agreements.
- Experience with pay-for-performance and/or shared riskcontracting.
- Prior contracting experiencecontracting in a pediatric health care setting is strongly desired.
- No professional certifications required
Requisition #: 22501