JOB SUMMARY: Responsible for managing and directing the development and implementation of new and existing managed care contracts. Monitors existing managed care contracts? financial and operational performance. Negotiates and administers contracts with managed care payers. Responsible for management of contract drafting, contract negotiations, and contract maintenance. Serves as strategic point of contact with managed care payors and consumers impacted by the operational aspects of managed care contracts. Is responsible for directing the development and implementation of processes to ensure managed care organizations are compliant with the terms of the managed care contracts and for the ongoing analysis of profitability and implementation of contract performance improvement strategies.
WHAT IS EXPECTED (Essential Functions):
Leads joint operations committee meetings.
Directs the resolution process of any issues and documents all activities. Maintains excellent working knowledge and application of state and federal regulations that affect contract enforcement. Examples include Texas Prompt Pay Act, ERISA, and COBRA.
Monitors contract volumes and analyzes profitability against expected levels of performance and initiates operational and/or contract modifications as appropriate.
Triages multi-faceted issues related to contract operational performance, interpretation and payor obligations between organization and the managed care organization.
Promotes accountability of all parties, communicates and coordinates process initiatives between all stake holders.
Ensures accuracy of managed care contract rates and language being loaded and accurately maintained in Managed Care Organization databases and claims payment systems by process implementation and ongoing audit procedures. -Represents the organization in dispute resolution venues such as meetings with payors and/or legal counsel, negotiations with payors and mediations; testifies under oath as a corporate Representative or fact witness in depositions, hearings and trials.
Provides input to new or amended managed care agreements from the perspective of contract enforcement.
Performs other position appropriate duties as required in a competent, professional and courteous manner.
Bachelor's degree required
10 plus years experience required
Baylor Scott & White Health