Under the direction of the Operations Director and Executive Director, this position is responsible for the negotiation, optimization and the operational management of the managed care contracts; Medi-Cal, Medicare, Commercial, PPO, FFS and etc.
Flexible, may require some evening and weekends
Hours worked per week may exceed 40 hours
Primary Duties and Responsibilities
Directs negotiation of managed care contracts including optimal capitation rates, fee-for-service reimbursements, bonus, incentives and etc.
Reviews, negotiates and renegotiates payor contracts including rates and contract language provisions.
Develops and maintains a complete library of payor contract documentation for each payor including contract summary documents, copies of all fully-executed contracts with related amendments, letters, policies and other operational reference materials.
Initiates, fosters and maintains productive long-term relationships with key payor contacts.
Collaborates with other departments to generate quantitative and qualitative data analyses to support negotiations.
Interfaces with other divisional managers to ensure operational efficiencies and effective administration of all contractual agreements.
Interfaces with internal departments to ensure the completion and submission of contractual documentation to contracted health plans or IPAs. (i.e., provider roster, credentialing information)
Ensures capture of incentives based on services provided: 120-day health assessments, timely encounter data submission, HEDIS, CHDP services and etc.
Negotiates contractual agreements with IPAs and health plans on specialty services such as OB, Mental Health, CPSP, DM Program and etc. based on fee-for-service model and health care outcomes.
Able to create and analyze the productivity and financial reports, make appropriate recommendations and corrective action plans.
Assists Operations Director in developing the IPA Network with other community clinics.
Partners with Operations Director to ensure compliance as required by Health Plans, IPAs and other regulatory agencies.
Participates in organizational meetings as requested.
Performs other duties as assigned.