Director Payor Contracting
Reports to the CFO and works with the executive and management team to design and implement a comprehensive contracting strategy that supports success in value-based reimbursement contracts from both a financial and quality perspective. Actively manages relationships with payers and uses data to strategically drive contracting from a system perspective. Engages with physicians and providers to include aligned improvements for value based quality improvement and utilization metrics. Ensures data and reports related to value-based performance are consistent and complete, providing usable and accurate data to manage value based contracts. Is a liaison with Centers for Medicare and Medicaid Services (CMS), commercial insurance companies and other payers, monitoring requirements and rules of participation in value-based incentive programs. Provides support to all value based activities and those carrying out strategy execution. Supports the management team by providing input into the value based planning process. Responsible for the communication and dissemination of appropriate contract and manage care information throughout TMCH.
ESSENTIAL FUNCTIONS:The essential job functions and level of work performed by the individual in this role are included below. These are not intended to be an exhaustive list of all job duties performed by the personnel occupying this position.
1. Develops, recommends and implements TMCH’s contracting strategy including value-based reimbursement by:
- Manages relationships with payers and is responsible for the system contracting strategy
- Provides leadership in the development and implementation of policies and procedures in operational systems for various insurance plans.
- Works with internal stakeholders to identify and resolve opportunities to align with payers
- Identifies all value based opportunities for each division of TMCH to include-inpatient, outpatient, physician practice and critical access hospitals in the network.
- Estimates and prioritizes the financial return and network value for all existing and potential value based programs both private and public.
- Developing plans to enable TMCH to reach savings and quality performance targets on governmental and commercial value-based reimbursement contracts.
- Directs and is accountable for the implementation of all new contracts including value-based reimbursement contracts, bundled payments and opportunities from commercial insurance companies.
- Accountable for the monitoring and presenting the performance of all TMCH contracts and value based initiatives.
- Developing plans to achieve evidence-based medicine and patient engagement.
- Interacts with departments involved in TMCH Care coordination and Quality Management functions.
- Key architect of Epic Healthy Planet, its development and use both internally and in conjunction with other users in this community.
- Providing education regarding value-based reimbursement contracts, and their requirements, to the employees of all participating ACO providers and entities.
- Develop a Post-Acute Care network, ensuring proper communication, referrals and performance.
- Guides the operational process of the Post-acute care network, care coordination, TMCH quality, MSSP ACO, CIN’s, Commercial ACO, bundled payments and other value based contracts as appropriate.
2. Ensures contractual and administrative compliance with all governmental and commercial program requirements by:
- Researches mandatory or voluntary value-based reimbursement programs implemented by CMS, and ensuring that TMCH entities are in compliance with the requirements of these programs.
- Manages relations with contractual compliance with contracted parties and state and federal programs.
- Ensuring all administrative requirements of current or future value-based reimbursement contracts are satisfied.
- Coordinating and conducting training as needed for administrative staff from TMCH or from other, affiliated entities.
- Developing procedures to effectively manage and monitor TMCH’s performance in value-based reimbursement contracts and other incentive programs to include readmissions.
- Works closely with Revenue Cycle team to resolve any commercial payor related payment issues.
- Works closely with Utilization Review nurses to resolve any denial or patient classification with payors issues.
- Works closely with Case Management to resolve any patient placement issues with payors.
- Works with all payors and assists is setting scheduled meetings (monthly / quarterly) as applicable to address revenue cycle, case management and utilization review issues.
3. Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:
Completing other job-related assignments and special projects as directed
Adheres to TMC organizational and department-specific safety, confidentiality, values, policies and standards.
Performs related duties as assigned.
EDUCATION: Bachelor's degree Business, Management, Nursing, Healthcare Administration, or a related field required.
EXPERIENCE: Eight (8) to ten (10) years of experience in managed care or healthcare finance, through which a background in Medicaid, Medicare and at least five (5) years value-based reimbursement experience, is required.
LICENSURE OR CERTIFICATION: None required.
KNOWLEDGE, SKILLS AND ABILITIES:
- Requires well-developed knowledge and understanding of value-based reimbursement contracts, ACO, bundled payments, CMS, insurance industry and healthcare delivery systems.
- Requires understanding of clinical quality metric requirements, such as those outlined in HEDIS guidelines.
- Requires a high level of interpersonal skills in order to ensure that effective relationships are developed, maintained and managed in a professional and effective manner with medical staff members, Hospital and System management team, patients, representatives of client organizations, business leaders, various public managers, physician groups and legal counsel.
- Demonstrates well-developed communication skills necessary to effectively communicate both verbally and in writing and to make presentations to individuals and small and large groups.
- Requires an in-depth understanding of contractual language.
- Requires strong organizational and leadership skills necessary to effectively establish priorities, coordinate workloads, meet deadlines, and ensure effective functioning of the department.
- Demonstrates a willingness and ability to be flexible and adapt to changes in the overall healthcare environment or specific contractual obligations.
- Must be open to making continuous changes and improvements in established workflows to better accomplish quality goals.