ST. CHARLES HEALTH SYSTEM
TITLE: Director, Payer Relations, Contracting and Health Plan
REPORTS TO POSITION: Senior Vice President / Chief Financial Officer
DEPARTMENT: Health Plan Administration
DATE LAST REVIEWED: March 16, 2020
OUR VISION: Creating America's healthiest community, together
OUR MISSION: In the spirit of love and compassion, better health, better care, better value
OUR VALUES: Accountability, Caring and Teamwork
DEPARTMENTAL SUMMARY: The Health Plan Administration Department is responsible for the following in our multi-hospital organization including: payer relations and contracting; developing new payment models; monitoring of payer performance; oversight and management of payer related quality and performance metrics; and management of the St.
Charles health plans including health, dental, vision, pharmacy, health savings accounts and flexible savings accounts.
POSITION OVERVIEW: The Director of Payer Relations, Contracting and Health Plan at St.
Charles Health System; provides strategic leadership and direction to guide and enhance the performance and financial position of St.
Charles Health System. The primary responsibility of this position is the development and management of coordinated systems-level contracting with health plans, clinical integrated network partners and oversight of St.
Charles' self-funded health plans in a manner that supports and improves the health of the Caregivers, employer groups, the community, and provides better value of healthcare costs. The person in this position will lead St.
Charles Health System into successful alternative payment models for Medicaid, Medicare and Commercial health plans in service to St.
Charles' stated strategic direction to shift to a value-driven revenue model. This position leads the development and negotiation of contract terms, and carries out policies and guidelines specific to Commercial, State and local government payer reimbursement contracts, employers and other third party payers, as well as development of payment methodologies related to existing and new models of care. This position is also accountable for the creation and management of the health plan administration infrastructure with oversight from the Health Plan Steering Committee, this position plays a key role in the development and implementation of long-term strategic goals for St.
Charles revenue model.
This position directly manages caregivers in the health plan administration department which consists of up to 2 FTE in addition to the director.
ESSENTIAL FUNCTIONS AND DUTIES:
Leads contracting strategy development and implementation to include development of contract models and negotiation of contract financial terms with payers, such as commercial plans, employer self-funded plans, government programs and fiscal intermediaries, and vendors, such as brokers, third party administrators, pharmacy benefit management firms, financial institutions and others.
In partnership with senior leadership and strategic partners develops, analyzes, implements and monitors implementation of value-based contracting models that support St.
Charles, both hospital and medical group, revenue model transition.
Establish acceptable contract language for hospital and medical group contracts, serves as St.
Charles contracting lead for care model redesign.
Facilitates contract dispute resolution between St.
Charles operations and external entities.
Serves as a key St.
Charles representative for various state and regional initiatives regarding payment reform, primary care access, and care model redesign.
Develops partnerships with healthcare and community leaders to improve access to care for the insured and uninsured. Maintains working knowledge of applicable laws, regulations and legislative changes affecting health plan administration.
Identifies new opportunities for payer contracting and health plan administration, through models of care redesign, new collaborations, partnerships and changes in health care reform with state and federal agencies, employers, health plans and others. Serves as key leader, in collaboration with the Population Health department, for financial and quality performance metrics for risk programs; oversight for successful completion of metrics to recoup withholds and surplus funds.
Responsible for the technical understanding, management and analysis of the contracts analytics module of Strata, St.
Charles' cost accounting and reimbursement modeling system.
Provides analytical support in conjunction with Revenue Cycle, Accounting and Finance for the purpose of reviewing contract financial performance, specifically advising the executive team and individual managers concerning financial implications of existing or proposed activities related to implementation of the health plan, development of contract strategy, negotiations, and the financial implications of contemplated business decisions.
Provides strategic thinking and planning to identify the areas in which collaboration could provide optimal benefit and innovative opportunities for the health plan, working with Caregivers, employer groups, state and government programs.
Lead and support, in partnership with the Chief Financial Officer, the Health Plan Steering Committee, a collaboration with Human Resources and Population Health, that provides the strategic oversight, benefit design approval, vendor relationship selection and other key decision making authority for the St.
Charles health plans.
Directly manages financial and vendor aspects of the health plan administration department, to include financial oversight, membership and enrollment, product development, provider network, provider relations, payer contracting and relations, provider and delegated credentialing, clinical utilization management and review with Population Health and clinical experts, vendor contracts and relationships, data reporting and analysis, and day-to-day operations of the health plan.
Works with key senior management and others to implement and provide direction that relates to the service and financial success of the Health Plan Administration Department. Collaborates, plans, coordinates, analyzes and implements strategic and tactical approaches to meet the clinical and financial expectations of St.
Responsible for budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control.
Provides and oversees team's delivery of customer service in a manner that promotes goodwill, is timely, efficient and accurate.
Hires, directs, coaches and monitors the performance of all direct reports, to develop and maintain a high performance team that meets organizational and department goals
Monitors and ensure all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals.
Collaborates with teams to review processes and identify/implement opportunities for improvements, applying Value Improvement Practice concepts and tools. Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Supports the vision, mission and values of the organization in all respects.
Provides and maintains a safe environment for caregivers, patients and guests.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization's corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
May perform additional duties of similar complexity within the organization, as required or assigned.
Required: Minimum of a Bachelor's degree in Business, Health Care Administration or in related field with comparable experience equating to same skill set required.
Preferred: MBA, MPA, MS preferred.
Required: Valid Oregon driver's license and ability to meet SCHS driving requirements.
Required: A minimum of seven years of experience in healthcare management and Managed Care/Payer Contracting in a healthcare setting.
Experience in new product development, organizational management, business communications, systems analysis, accounting/fiscal systems and reimbursement, office and personnel management. Proven experience in building and leading teams, effectively managing change, solid business acumen leveraging resources, with demonstrated visionary skills. Skilled in handling potentially adversarial situations requiring resolution; ability to build and maintain a high level of trust and consensus over complex issues. Understanding the dynamics of change management and sensitivity to an industry and organization undergoing significant changes.
PERSONAL PROTECTIVE EQUIPMENT
Must be able to wear appropriate Personal Protective Equipment (PPE) required to perform the job safely.
ADDITIONAL POSITION INFORMATION: N/A
Continually (75% or more): Use of clear and audible speaking voice and the ability to hear normal speech level.
Frequently (50%): Sitting, standing, walking, lifting 1-10 pounds, keyboard operation.
Occasionally (25%): Bending, climbing stairs, reaching overhead, carrying/pushing or pulling 1-10 pounds, grasping/squeezing.
Rarely (10%): Stooping/kneeling/crouching, lifting, carrying, pushing or pulling 11-15 pounds, operation of a motor vehicle.
Never (0%): Climbing ladder/step-stool, lifting/carrying/pushing or pulling 25-50 pounds, ability to hear whispered speech level.
Exposure to Elemental Factors
Never (0%): Heat, cold, wet/slippery area, noise, dust, vibration, chemical solution, uneven surface.
Blood-Borne Pathogen (BBP) Exposure Category
No Risk for Exposure to BBP
Schedule Weekly Hours:
First Shift (United States of America)
Is Exempt Position?
Scheduled Days of the Week:
Shift Start & End Time:
0800 - 1700
St. Charles Health System