Payer Contracting Manager - Managed Care
Rush Health is a clinically integrated network of physicians and hospitals working together to improve health through high quality, efficient health services covering the spectrum of patient care from wellness, prevention and health promotion, to disease management and complex care management. Our network includes Rush University Medical Center, Rush Oak Park Hospital, Rush Copley Medical Center, Riverside Medical Center and over 1900 professional providers. All hiring is done through Rush University Medical Center Human Resources. The Payer Contracting Manager is responsible for developing and maintaining relationships with third party payers including but not limited to Managed Care Commercial payers, Medicare Advantage payers and Medicaid payers and negotiating managed care agreements both fee-for-service (FFS) and value based care (VBC) with these third party payers on behalf of Rush Health Participating Hospitals and Physicians (Members). These negotiations shall be under the direction of the Directors of FFS Payer Contracting and VBC Payer Contracting. This responsibility also includes management of referral contracts with other physician organizations. This position shall also assist in Member education regarding payer agreements and in monitoring and enforcing payer compliance with contract terms. This position is pivotal to capturing and retaining business for our Members and growing and maximizing financial performance. Exemplifies the Rush mission, vision and values and acts in accordance with Rush policies and procedures.
Negotiate and maintain fee-for-service (FFS) contracts with third party payers as assigned by the Director, FFS Payer Contracting.
Assist in the development and negotiation of value based care (VBC) risk contracts with third party payers as assigned by the Director, Value Based Payer Contracting.
Negotiate, analyze and model current, proposed, and final FFS pricing terms for hospitals and physicians in accordance with Rush Health pricing standards.
Under the direction of Director, Value Based Payer Contracting, assist in negotiation of VBC financial risk terms working in conjunction with Analytics and actuary, when needed, to develop financial risk models to analyze payer VBC proposals including ACO, shared savings/shared risk, capitation, global bundled pricing and % of premium contracts.
Under the direction of Directors Contracting, evaluate and initiate new FFS and VBC contract opportunities.
Negotiate FFS contract language in accordance with Rush Health language standards.
Under the direction of Director, Value Based Payer Contracting, assist in negotiation of VBC contract language and performance terms in consultation with Rush Health business and support departments (Clinical, Analytics, HIT, Payer Relations, Legal, Finance). This includes legal, compliance, quality measures, reporting and data exchange requirements. Coordination through VBC Workgroup.
Monitor and analyze performance of third party payer agreements including profitability, volume, strategic initiatives and payer compliance issues.
Develop and maintain relationships with third party payers.
Establish and maintain a system of reviewing and assessing changes in the Federal and or State regulations in regards to Managed Care contracts.
Achieve and maintain a full understanding of Medicare and or Medicaid pricing reimbursement and structure for both physicians and hospitals.
Work closely with Directors, Contracting to develop and monitor contract negotiation schedules, timelines and annual pricing renewals.
Assist in the development and implementation of an annual strategic plan for third party payer contracting, including the continued development of VBC opportunities and implementation of pricing strategies and contract language standards.
Assist Director, Value Based Payer Contracting in coordination and management of VBC program initiatives and contract terms with governmental payers including CMS and programs such as MSSP, BPCI.
Manage negotiations for all "ad-hoc" individual case agreements in accordance with Rush Health policies and standards.
Responsible for maintenance and ongoing auditing of all physician and hospital pricing in the contract management system.
Assist Directors Contracting in contract implementation of FFS and VBC contracts for Members.
Work closely with Payer Relations to ensure all fee schedules and Contract Summaries on the Rush Health website are accurate and current.
Maintain and keep updated "contracted designated" fields for physician and hospital Contract Summaries
Assist Director, Value Based Payer Contracting in maintenance of VBC contract summaries including performance targets and measures matrix, timelines, contract requirements and deadlines.
In coordination with Director, Value Based Payer Contracting and Payer Relations, monitor and manage VBC payer compliance issues including rosters, assignment, reports, delivery dates, fees, audits.
Monitor and analyze changes in payer VBC programs and policies that may affect contract performance and initiate negotiations as warranted.
Coordinate any credentialing or request for information (RFI's) requirements for new COE and VBC initiatives.
Work closely with Payer Relations in development of orientation and educational materials to educate Members regarding payer contract terms, Rush Health reporting tools and market issues.
Work closely with Payer Relations and Member revenue cycle teams to resolve contract compliance issues with third party payers and ensure the negotiated contract rates are implemented in payer systems and paid in accordance with the agreements.
Participate in monthly payer joint operating committee (JOC) meetings; serve as lead role for addressing contract issues.
Staff Committees as assigned.
Other duties and responsibilities as assigned.
Position Qualifications Include:
Bachelor's Degree required; Master's degree in Health Care Administration or Business preferred.
At least five (5) years experience in a managed care environment with direct payer contracting experience.
Experience in multi-facility health system, large academic medical center or insurer environment.
Strong financial knowledge base related to all managed care reimbursement methodologies including the various fee-for-service structures and risk based structures such as capitation, shared savings and global payments.
Specific and thorough understanding of physician and hospital coding, claim forms, payer EOBs and reimbursement methodologies.
Understanding of contract law highly desirable.
Experience with governmental programs related to Medicare, Medicaid and Medicare Advantage highly desirable.
Knowledge base of population health management activities and value based care delivery models
Strong written and verbal communication skills.
Strong analytical and problem solving skills.
Strong attention to detail and well organized.
Adapts well to rapid change and multiple, demanding priorities.
Excellent time and project management skills.
Must be able to work on multiple projects simultaneously.
Ability to network internally and externally to build relationships, facilitate discussion and resolution.
Microsoft Office Suite advanced proficiency, particularly MS Excel.
Ranked among the top academic medical centers in the country, Rush University Medical Center is an outstanding place to enhance your career. Everything we do centers on one goal: improving patient care.
Rush is an academic health system comprising Rush University Medical Center, Rush Copley Medical Center and Rush Oak Park Hospital.
Leading academic medical center, acute care hospital w/ 664 licensed beds.
Ranked among the top 20 best places to work in healthcare by Indeed.
Rush is an equal opportunity employer. We evaluate qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, and other legally protected characteristics.
Rush University Medical Center