Program Manager of Alternative Payment Strategy

Industry: Government & Non-Profit

  •  

8 - 10 years

Posted 49 days ago

This job is no longer available.

This position is responsible for the development, maintenance and implementation of alternative payment methodologies (APM). This position has significant external visibility and requires strong collaboration with external stakeholders

The primary focus of this position is the State of Rhode Island’s Accountable Entity (AE) Program. In alignment with the Neighborhood’s Medicaid Managed Care contract with the Rhode Island Executive Office of Health and Human Services (EOHHS), this position develops implements, and oversees the contracts between Neighborhood and the state’s certified entities for the organization’s Medicaid products. These functions initially report to the Director of Strategy and Business Development and will subsequently transition to the Director of Provider Network Management.

As the AE Program matures, the secondary focus of this position is the development, maintenance and implementation of additional alternative payment strategies. For Neighborhood’s full portfolio of products (i.e. Medicaid, commercial and Medicare).

Responsibilities

  • Management of direct and matrix staff
  • Ability to train staff, as applicable
  • Manages, directs and mentors staff
  • Serve as primary liaison to internal and external stakeholders. Partner with internal and external stakeholders to develop a collaborative approach supporting each AE
  • Develop, implement and communicate APM and AE Program requirements and collaborate with internal and external partners on the vision and strategy for supporting APM and AE success and growth.
  • Direct cross-functional teams to create policy and procedures and documentation associated with APM and AE business processes. Collaborate with operational business areas to review and identify gaps and develop procedures for remedy and oversight of gaps
  • Provide day-to-day management of AE Program, including close collaboration with direct and matrix program staff, problem resolution, data sharing and other activities to assist in the facilitation of a successful arrangement with all contracted AEs
  • Responsible for creating performance reporting and dashboards
  • Responsible for knowledge of CMS, Federal and State laws and requirements and other applicable industry standards and benchmarks
  • Responsible for leading, facilitating, collaborating and developing the Joint Operating Committees (JOC) and sub-committees
  • Review, understand and communicate analytics internally and externally, as appropriate
  • Ability to negotiate and execute complex contractual relationships to align with specific corporate and department initiatives, strategic goals and objectives
  • Act as the subject matter expert (SME) in the area of health care improvement, with experience leading delivery system change to significantly improve quality and resource use
  • Work closely with and provide direction for dedicated staff within Financial Analysis, Business Intelligence, Healthcare Effectiveness Data and Information Set (HEDIS) and Care Management teams
  • Responsible for complying with Neighborhood’s Corporate Compliance Program, Standards of Business Conduct, applicable contracts, laws, rules and regulations, policies and procedures as it applies to individual job duties, the department, and the Company. This position must exercise due diligence to prevent, detect and report unlawful and/or unethical conduct by fellow co-workers, professional affiliates and/or agents
  • Other duties as assigned

Qualifications

Required:

  • Demonstrated experience cultivating and supporting strong business relationships; Skilled communicator and negotiator with proven track record of success
  • Comprehensive knowledge of health insurance; insurance laws and regulations, including Medicare and Medicaid policies; claims processing; medical and insurance terminology and procedure and diagnostic codes
  • Comprehensive knowledge of provider reimbursement mechanisms including provider financial components and performance measure sets
  • Comprehensive understanding of current trends and business solutions for Managed Care and Accountable Care Organizations
  • Demonstrated success as a senior leader in a matrix organization, leading high-level cross- functional teams to achieve the goals of the company and department
  • Demonstrated understanding and experience in all aspects of contract negotiation, financial analysis, data analysis, contract implementation and maintenance of contractual agreements
  • Excellent written and strong business communication skills (written and verbal) public relations, presentation and facilitation skills
  • Ability to manage data and processes in multiple platforms
  • Ability to manage multiple projects simultaneously
  • Intermediate to Advanced skills in Microsoft Office (Word, Excel, PowerPoint, Outlook)
  • Leadership experience and the ability to lead others to achieve desired results
  • Proven ability to manage vendors to ensure service levels and performance is met as contracted
  • Proven ability to work cross-organizationally to achieve the goals of the organization and department
  • Seven (7) + years’ experience with a managed care organization or a health care related organization (HMO; Medicaid, Medicare)
  • Five (5)+ years’ experience with commercial, Medicaid or Medicare contracting and reimbursement
  • Three (3)+ years’ experience managing staff including ability to lead, motivate, and develop staff, with effective interpersonal and conflict resolution skills
  • Bachelor’s degree in Health Administration, Business Administration, Public Health or a related field or an equivalent amount of education and experience
  • Ability to travel including reliable transportation, a valid driver’s license and proof of insurance

Preferred:

  • Experience leading an Accountable Care Organization (ACO) program
  • Experience in Project Management
  • Experience in Cognos
  • Experience in MedInsight
  • Experience in SharePoint
  • Knowledge of Quality Improvement Processes (e.g. Lean, Six Sigma)
  • Master’s degree in Health Care Administration, Business Administration or Public Health or a related field

Organizational Competencies:

  • Judgment and Decision Making
  • Gets Results
  • Collaboration and Teamwork
  • Business Awareness
  • Customer Focus

Job Specific Competencies:

  • Problem Solving/Analysis
  • Planning & Organizing
  • Open Communication
  • Relationship Building & Networking
  • Flexibility & Achieving Change

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