Reports to the Chief Financial Officer of Beacon Health System (BHS). Responsible for the strategic development, implementation and administration of all managed care activities, including managed care contracting, negotiating payment rates, risk-based payment structures and value-based incentive arrangements, while working collaboratively with System leadership to optimize the Health System's overall payment rate. Responsible for leadership and continued development over Beacon's Accountable Care Organization (ACO), Physician Hospital Organization (PHO), and participation in managed care networks.
Responsible for Medicare Advantage and Managed Medicaid program participation rate and incentive negotiation. Establishes and oversees direct-to-employer sales programs. Provides payer/provider credentialing services for all providers throughout the Health System. Oversees Care Coordination services for the Health System.
Directs and oversees the Managed Care area by:
- Developing short and long-term goals and objectives consistent with the goals of Beacon Health System; developing an annual operating plan to encompass these functions.
- Negotiating direct payment and value-based payment arrangements with Commercial, Medicare and Medicaid payers to obtain contracts for all of Beacon's providers including our hospitals, medical group and ancillary providers with the goal to optimize the Health System's overall payment rate.
- Negotiating direct to employer contacts through PHO and other network arrangements to meet the Health System's goals and objectives.
- Periodically evaluating contract economic effectiveness, continued participation and renegotiation of contracts to meet the Health System's goals and objectives.
- Responds to and works collaboratively with employers, brokers and managed care networks. Request for Proposals (RFP's) for the PHO and direct contracts with the Health System.
- Developing and deploying sales programs to promote Beacon's programs to employers.
- Leading and overseeing the ACO's overall effectiveness and ensures the alignment to Beacon's goals and objectives.
- Leading and overseeing the PHO's overall effectiveness and ensures the alignment to Beacon's goals and objectives.
- Working with Michiana Medical Associates (MMA) physicians to coordinate PHO activities.
- Preparing, subject to approval, an annual operating budget for areas of responsibility. Also, monitoring budget and controlling expenditures to ensure achievement of budget goals and objectives.
- Educating Beacon leadership on Managed Care-related topics.
Leadership Competencies
- Drives Results - Consistently achieving results, even under tough circumstances.
- Customer Focus - Building strong customer relationships and delivering customer-centric solutions.
- Instills Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.
- Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
- Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.
- Agility- ability to flex scheduling with needs of provider, promoting a growth mindset.
ORGANIZATIONAL RESPONSIBILITIES
Associate complies with the following organizational requirements:
- Attends and participates in department meetings and is accountable for all information shared.
- Completes mandatory education, annual competencies and department specific education within established timeframes.
- Completes annual employee health requirements within established timeframes.
- Maintains license/certification, registration in good standing throughout fiscal year.
- Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
- Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
- Adheres to regulatory agency requirements, survey process and compliance.
- Complies with established organization and department policies.
- Available to work overtime in addition to working additional or other shifts and schedules when required.
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
- Leverage innovation everywhere.
- Cultivate human talent.
- Embrace performance improvement.
- Build greatness through accountability.
- Use information to improve and advance.
- Communicate clearly and continuously.
Education and Experience
- The knowledge, skills and abilities as indicated in this job description are normally acquired through the successful completion of a Bachelor's degree in Business, Economics, Marketing or a related field. A Master's degree is preferred. Five to ten years of Managed C experience working in a health system or insurance environment with background in Commercial, Medicare and Medicaid contracting is required. A previous record of successful contract negotiation is required. Management/leadership experience is required.
Knowledge & Skills
- Demonstrates advanced knowledge of healthcare managed care delivery systems which includes all aspects of payer products including commercial HMO, PPO, etc., direct to employer products, Medicare Advantage products and Managed Medicaid products.
- Requires in-depth knowledge of employer health benefit products/plans, including: health/medical, dental, workers compensation and case processing (proposal, renewal, plan design, billing, claims, etc.).
- Requires an in-depth understanding of managed care contractual language terms and obligations.
- Requires an in-depth understanding of the key drivers to the Health System payment rate.
- Requires knowledge of the regulatory environment affecting healthcare delivery systems and managed care, including Medicare, Medicare Advantage and State-specific Medicaid guidelines.
- Demonstrates independent judgment, research and analytical skills necessary to develop programs, evaluate projects.
- Requires knowledge of marketing and sales.
- Demonstrates the interpersonal skills necessary to effectively interact with representatives of client organizations, business leaders, various public managers and leaders and physician groups in situations requiring negotiations and persuasion in a tactful and positive manner.
- Demonstrates the communication skills (both verbal and written) necessary to clearly articulate information to diverse individuals. Also requires the ability to give effective presentations before small and large groups.
- Requires knowledge of the requirements of regulatory and accreditation organizations.
Working Conditions
- Works in an office environment. Some travel is required.
Physical Demands
- Requires the physical ability and stamina to perform the essential functions of the position.
