This position is responsible for managing the Value Based Agreements and Risk contracting activities for Dignity Health’s hospitals in Southern California and surrounding areas. The hospitals involved are: Glendale Memorial Hospital and Health Center, and California Hospital Medical Center, St. Mary Medical Center, Community Hospital of San Bernardino, St. Bernadine Medical Center, and Northridge Hospital. This position will be based in Southern California area and will require travel to other Dignity Health offices and/or Physician Group offices and all affiliated Management Services Organizations (MSO).
The position is responsible for: planning and organization of Joint Operations meetings with each affiliated capitated IPA/MG who must collaborate with the respective MSO staff who is directly responsible for ensuring clear communication, timely/accurate dashboard reports, financialreports, risk pool settlements, etc. Director of Risk Contracting establishes priorities of effective risk pool management and the areas of focus in support of pool profitability, process development and implementation for the Southern California service area Value Based Agreements; contributing to strategic planning; strategy implementation; maintaining and developing relationships with Dignity Health’s internal departments & stakeholders, with Dignity Health’s affiliated Physician Groups/Foundation, negotiating and maintenance of entire Ancillary/Vendor network and provider agreements associated with Dignity Health’s Institutional capitated riskcontracts and creating Centers of Excellence where applicable; Externally with affiliated Physician Groups and Management Services Organizations (MSOs); planning, organizing, directing and conducting IPA negotiations, risk pool settlements, Risk Share Agreement renewals in collaboration with the respective hospital Director of Managed Care, and implementation of managed care agreements with current and prospective purchasers or providers of healthcare services on behalf of DIGNITY HEALTH. The contracts include such payer entities as HMO’s (various products: MA, Medi-Cal, Duals, Commercial), and various risk bearing organizations such as Banker Hospitals, IPAs/Medical Groups and Restricted Knox-Keene organizations.
By securing optimal reimbursement and protecting the interests of the hospitals in contract negotiations and the implementation and management of managed care contracts and relationships, this position is essential to DIGNITY HEALTH and individual hospital’s financial performance related to Value Based Agreements and the overall management of In Network and Out of Network spend.
This position is also responsible for collaboration, communication, and facilitation between Managed Care and other key stakeholder departments within DIGNITY HEALTH including special projects that involve collaboration with IPAs to optimize reimbursement for OB Kick payments, HCC reimbursement maximization, Out of Network utilization reductions projects, Quality Incentive program coordination, Population Health initiatives, Community Resource coordination, Capitation revenue and reconciliation oversight of MSOs reports and responsibilities, and all other payment innovation associated with Risk Contracting arrangements.
- Negotiate contracts with existing payors (health plans and physician organizations) based on prior contract performance, future potential and current strategic and financial goals.
- Develop and enhance relationships with internal and external contacts. Proactively plan, prioritize, and communicate regarding projects, issues, and negotiations to ensure relationships are maintained and DIGNITY HEALTH’s values are demonstrated on a day-day basis and when difficult business decisions need to be made.
- Lead and coordinate activities of personnel in the analysis, negotiation, and management of existing managed care contracts. This includes the maintenance of a variety of activity reports in support of financialreporting as related to managed care contract performance.
- Analyze contractual language for functional, financial, and ethical appropriateness. Determine compliance with established legal requirements and negotiate contractlanguage for signature in a manner consistent with the authority as delegated to this position by DIGNITY HEALTH legal counsel.
- Coordinate implementation of HMO, PPO, and other managed care contracts with Patient Financial Services, Admitting, Case Management, etc. Develop and maintain systems and procedures to disseminate pertinent contract information in a timely manner to appropriate regional and hospital personnel.
- Represent DIGNITY HEALTH in meetings with other organizations, associations, providers and payors regarding all aspects of managed care.
- Ensure the maintenance of comprehensive current correspondence and contract files relating to managed care agreements.
- In coordination with the Directors of Patient Financial Services and Central
Business Offices (CBO’s), develop, implement and maintain unambiguous rate structures that ensure efficient, automated billing and collections to ensure receipt of proper payment from contract payors. Assist PFS as necessary with updates to insurance code information.
- As appropriate, coordinate with IT and other system and hospital departments regarding the operation, utilization and selection of managed care related information systems such as HBO-CPA, Ascent, and other systems. Ensure the maintenance of the managed care contract rate information, modeling, updated reports and analysis for expected reimbursement systems.
- Work in tandem with other Managed Care Directors and personnel regarding managed care activities.
- Serve in a lead role within DIGNITY HEALTH regarding managed care activities, including serving on various DIGNITY HEALTH committees, task forces and negotiating teams.
- Ensure that all contracts and departmental actions follow the HIPPA regulations/guidelines.
- As requested, provide consultative support to the hospital senior and middle management teams with respect to managed care and related issues. Perform work on unique projects as requested by the Vice President, Managed Care and/or Senior Vice President, Managed Care.
- Prepare agendas, attachments, analysis, recommendations and minutes for Managed Care meetings as needed.
- Decisive, effective management and leadership skills
- Capable of maintaining and building relationships while simultaneously achieving DIGNITY HEALTH’s short term and long term business objectives
- Comprehensive advanced knowledge of healthcare managed care principles
- High degree of effective oral and written communications skills
- High degree of effective advanced analytical and problem-solving skills and judgment with specific application to hospital, medical and financial data
- Understands revenue, expenses, contribution margin and operating margin
- Strong ability to consistently prepare and review accurate analyses, projections, and rate proposals
- Must be able to effectively function in situations involving high-level negotiation activities and possess effective negotiating skills
- Advanced knowledge of legal principles relating to managed care contracting issues at a level sufficient to exercise independent judgment in finalizing contractlanguage
- Comprehensive knowledge of healthcare market and an understanding of hospital operations
- Working knowledge of hospital finance and accounting, including patient accounting principles and operations
- Advanced knowledge of information systems and their application to managed care and hospitals
- Working knowledge of DRGs and other coding methodologies as they apply to managed care; ability to ensure reimbursement rate structures are clear and may be efficiently adjudicated
- Must be able to organize and prioritize activities with specific attention to details and higher level strategies and consistently demonstrate effective time management skills
- Direct understanding of the HIPPA regulations/guidelines
This position requires graduation from a recognized college or university with a bachelor’s degree in business, hospital administration, public health or related field. At least seven to ten years of experience with progressive responsibility in the healthcare environment, at least five of which should be in a managed care position with demonstrated competencies or an equivalent combination of experience and education. A thorough understanding of the healthcare market, managed care, physician organizations, and knowledge of relevant state and federal regulations is mandatory. Experience in a hospital setting with working knowledge of Institutional capitation is preferred