Senior Contract Manager, Medicare

Point32health, Inc Canton , MA 02021

Posted 2 weeks ago

We enjoy the important work we do every day on behalf of our members.

Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated.

This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.

Job Summary

Job Description

JOB DESCRIPTION SUMMARY:

The position of Senior Contract Manager for Senior Products serves as the primary point of contact with provider organizations to negotiate and manage contracts with network physicians and hospitals. This individual is the primary lead during negotiations and is accountable for the financial and legal terms negotiated with the provider organizations.

This individual will assure that contract terms are consistent with the corporate and Senior Products contracting strategies, and are negotiated within the established legal and financial guidelines as established by Tufts Health Plan. This individual will assure that any non-standard elements of any contract negotiation have been properly researched and communicated to key internal stakeholders. This individual also will coordinate with the appropriate personnel from the Provider Engagement and Implementation team to oversee the successful implementation of contract terms within the organization's system and processes.

In addition, the Senior Contract Manager is responsible for training and supervising one or more internal team members as needed, and for leading projects within the department. The individual will mentor, guide and support staff within the department to help assure the successful achievement of business and professional goals.

This may include, but is not limited to, reviewing contracts and/or developing contract templates, providing guidance on contracting strategies, and facilitating a resolution to complex financial, legal, compliance, reporting or implementation challenges. Should there be a business need for this individual to manage direct reports, they will be expected to provide coaching, feedback and direction to staff to assure the successful achievement of business and professional goals.

This includes developing recruitment and retention plans for such individual(s).

The Senior Contract Manager will also provide support to the Director in developing contracting strategies to accommodate the ever changing Medicare Advantage market, including exploring new product offerings, potential network expansion/development and alternative contracting models. This individual will represent Network Contracting in both internal and external meetings specific to contracting related interests as they apply to Clinical Services, Risk Adjustment, Actuarial services, Claims and Sales within the Senior Division or enterprise wide functions if applicable.

KEY RESPONSIBILITIES:

Essential functions occur simultaneously. The employee must be able to appropriately handle each essential function, prioritize with minimal direction, and seek assistance when necessary. These functions need to be performed on a consistent and regular basis, using good judgment.

ESSENTIAL FUNCTIONS

% OF TIME

1.Negotiate contractual arrangements with established or potential network providers for the Senior product lines, within budgeted targets and regulatory requirements. Direct analyses to support contract negotiations, oversee the development of contract documents, and summarize contractual terms, legal and financial, for implementation by the Provider Engagement and Implementation area.

25%

2.Lead Senior Leadership meetings between THP and our provider network. Effectively articulate to THP's position on key issues relevant to the contract negotiation. Manage and position the negotiation so that THP meets the key objectives that have been identified for the contracting cycle.

15%

3.Work closely with the legal and compliance departments to assure contract provisions are consistent across providers and assure all applicable legal terms are included in the signed contract.

10%

4.Summarize and document any non-standard elements of the negotiations. Communicate results to applicable internal departments.

10%

5.Understand, with a high degree of specificity, important business aspects such as Medicare and Medicaid rules and regulations, reimbursement methodologies, claims trend, provider/TMP financial performance, and any analytical tools utilized by THP to understand the performance, financial and otherwise, of the provider network.

10%

6.Lead and/or participate in cross functional projects and meetings to support key business initiatives (such as managing Senior Division projects related to specific contracting strategies, facilitating internal ad hoc groups to address contracting issues, representing Network Contracting in assigned project teams, communicate status of negotiations and document key financial and legal terms).

10%

7.Recruit, train, supervise and/or manage direct reports to assure successful achievement of business and professional goals. as the business needs define. Support the execution of direct reports in performing all essential job functions of the Associate Contract Manager / Contract Manager role as described above.

20%

KNOWLEDGE, SKILLS AND ABILITIES:

EDUCATION

The position requires a Bachelor's Degree. Master's degree preferred

EXPERIENCE

Requires a minimum of 7-10 years of progressive experience in a managed health care environment with a thorough

knowledge of the health care market and the needs/concerns of health care providers. Direct contract negotiation or

relevant experience is also required. Understanding of Medicare, Medicare Advantage and the Medicaid markets is highly

desirable. Prior experience with mentoring, training and/or supervising staff is preferred.

Demonstrated ability to communicate effectively with physician leaders and high-level hospital, medical group or health

center administrators. Contract negotiation experience, including negotiating value based financial models, is required.

Work requires sound knowledge of health care reimbursement methodologies, as well as advanced financial analytic ability. Experience with Microsoft office analytic tools (e.g., Excel / MS Access) and developing executive level Powerpoint presentations is required.

COMPLEXITY

Must be highly motivated individual with excellent organizational skills to manage large volumes of information and

multiple assignments; attention to detail is key.

Requires the ability to understand, interpret and educate others on all aspects of a contract: financial, legal, and operational

with emphasis on implementation of contract terms. Working knowledge of federal and state regulations as they apply to

senior products (e.g., Medicare Advantage and over 65 dual-eligible populations).

Possess strong customer focus and expertise in setting and managing customer expectations.

Requires initiative, sound judgment, and the ability to work independently under pressure in a constantly changing

environment balancing multiple priorities. Require the ability to learn and apply Tufts Health Plan's policies consistently

and seek out guidance when necessary.

Must be able to conceptualize and envision the impact of change, and propose new ways to do business. Must be flexible

and a proponent/champion of change.

PERSONAL CONTACTS

Excellent interpersonal skills are necessary to develop strong working relationships with internal and external contacts.

Requires excellent diplomacy, oral and written communication skills as well s the ability to coordinate efforts amongst

various departments at THP. Must be able to work cooperatively as a team member. Must possess the skills to train/

educate and manage department staff.

CONFIDENTIAL DATA:

All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is

considered confidential. Strict confidentiality is required for all clinical information that one encounters and works with as

part of the job. Requires as high degree of confidentiality with regards to the financial and political issues associated with

contractual agreements. Requires confidentiality regarding the Health Plan's initiatives, strategies and product -related

contractual development.

MENTAL/PHYSICAL REQUIREMENTS

Fast-paced office environment handling multiple demands. Moderate use of telephone and extensive use of PC required.

Requires that the individual be organized while being readily adaptable to changes in work priorities.

PHYSICAL WORK ENVIROMENT

Business environment.

ADDITIONAL REQUIREMENTS (TRAVEL, WEEKEND HOURS)

Must be flexible to travel and work additional hours (early morning, evening and weekend). Valid driver's license and the

ability to provide transportation are required.

Requirements

Requires a minimum of 7-10 years of progressive experience in a managed health care environment with a thorough

knowledge of the health care market and the needs/concerns of health care providers. Direct contract negotiation or

relevant experience is also required. Understanding of Medicare, Medicare Advantage and the Medicaid markets is highly

desirable. Prior experience with mentoring, training and/or supervising staff is preferred.

Demonstrated ability to communicate effectively with physician leaders and high-level hospital, medical group or health

center administrators. Contract negotiation experience, including negotiating value based financial models, is required.

Work requires sound knowledge of health care reimbursement methodologies, as well as advanced financial analytic ability. Experience with Microsoft office analytic tools (e.g., Excel / MS Access) and developing executive level Powerpoint presentations is required.

What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!

Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated.

This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law.



icon no score

See how you match
to the job

Find your dream job anywhere
with the LiveCareer app.
Mobile App Icon
Download the
LiveCareer app and find
your dream job anywhere
App Store Icon Google Play Icon
lc_ad

Boost your job search productivity with our
free Chrome Extension!

lc_apply_tool GET EXTENSION

Similar Jobs

Want to see jobs matched to your resume? Upload One Now! Remove
Senior Medicare Compliance Business Partner

Tufts Health Plan

Posted 2 weeks ago

VIEW JOBS 1/13/2022 12:00:00 AM 2022-04-13T00:00 We enjoy the important work we do every day on behalf of our members. Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law. Job Summary The Medicare Compliance Senior Business Partner is responsible for compliance oversight of two or three Tufts Medicare Preferred operational areas to ensure business activities conform to the rules and requirements of the Centers for Medicare and Medicaid Services (CMS). The Medicare Compliance Senior Business Partner also is responsible for the design, establishment and implementation of annual Compliance Department and Medicare Compliance team initiatives and for the support and training of Medicare Compliance Business Partner colleagues. The Medicare Compliance Senior Business Partner establishes and maintains effective business relationships with each of his/her assigned business areas. The Medicare Compliance Senior Business Partner advises and supports business leaders and their employees toward operations that prevent and detect noncompliant activities. The Medicare Compliance Senior Business Partner possesses a deep knowledge of the people, systems and rules of each business area and uses his/her expertise, independent judgment and discretion to develop efficient and effective compliance oversight strategies. The Medicare Compliance Senior Business Partner is also responsible for receiving and analyzing CMS rules and requirements and communicating them to the business areas effectively and timely. The Medicare Compliance Senior Business Partner initiates and plans business meetings to discuss and implement new rules and requirements. The Medicare Compliance Senior Business partner also establishes an effective monitoring program with his/her business area(s) and analyses the results to determine compliance and reports the findings to the Medicare Compliance Officer, Chief Compliance and Ethics Officer and the business departments and leaders. In partnership with the Director of Medicare Compliance, the Medicare Compliance Senior Business Partner creates implements and monitors the compliance program to ensure it is effective, efficient and provides value to the business areas. These roles also lead the business through a risk assessment process whereby they alter and modify business practices and strategies to prevent and mitigate risk. These roles also collaborate with the business leaders and employee to prepare for audits and regulatory oversight. In collaboration with the Medicare Compliance Officer and the Medicare Audit Program Manager, the Medicare Compliance Senior Business Partner will also have primary responsibility for driving annual Compliance Department and Medicare Compliance team initiatives including, for example, designing, developing and implementing enhanced monitoring activities (for all business areas) and supporting audit readiness activities. The Medicare Compliance Senior Business Partner also will be responsible using data visualization to enhanced reporting to all business areas, the Compliance Steering Committee, and the Audit & Compliance Committee of the Board of Directors. Job Description * Design and Implement Annual Compliance Department and Medicare Team Initiatives: Develop and implement critical Compliance Department and Medicare Team initiatives, process enhancements and infrastructure improvements including, for example: * In collaboration with Medicare Audit Program Manager and Medicare Compliance Officer, develop and implement an improved and enhanced monitoring process and tools across all business areas. * Create reporting templates utilizing data visualization tools for reporting to business areas, senior management, Compliance Steering Committee and Audit & Compliance Committee; provide reporting support for the entire Compliance Department, including other lines of business. * Provide ongoing support for Audit Program Manager and Senior Manager of Corporate Compliance in Compliance department audit readiness activities (Compliance Program Effectiveness). * CMS rules and requirements: Receive, read and understand incoming CMS communications and develop a strategy to communicate them to and implement them with the business areas. * Develop and maintain effective business relationships: attend business meetings, job shadow in each area to learn more about the people, systems and processes of each area and establish a regular frequency of meeting to discuss and manage compliance strategies. * Monitor and respond: In partnership with the Medicare Compliance Officer and business areas, establish and maintain an effective monitoring program. * Review and report the results of the monitoring program to the Medicare Compliance Officer, Chief Compliance and Ethics Officer, business leaders and employees. * Assess, mitigate and report risk: In collaboration with the Medicare Compliance Officer and the business areas, create and implement a risk assessment, mitigation and reporting process annually or when needed when compliance issues arise. * Effective Compliance Program: Create and maintenance an effective compliance program (writes policies and procedures, assess and change effectiveness of compliance structures, assess risk, improve program elements, help establish and maintain state of audit readiness). * Train and Educate: Create and deliver compliance trainings and requirements to business areas and Medicare Compliance team colleagues about compliance requirements and strategies: annual, ad hoc, when compliance issues arise, proactively. Serve as a resource and subject matter expert for Medicare Compliance team colleagues. * Create and execute annual workplan: create and implement a workplan for each business areas that will deliver guidance, value and a sound compliance strategy for each area. Requirements EDUCATION: * Bachelor's Degree or equivalent experience and education required. * Health care, public policy, legal or business degree experience preferred. * Certification in Health Care Compliance preferred. EXPERIENCE: * Minimum of four years Compliance, Ethics, FWA or directly related experience required. * Health Plan operations and/or compliance operations experience required. SKILL REQUIREMENTS: * Subject matter knowledge: possesses a working knowledge of Medicare Part C and Part D, the CMS contract, the Medicare Managed Care Manual and Prescription Benefit Manual, ongoing changes in CMS regulatory guidance in the form of memos and other notices, as well as other State and Federal laws and regulations (e.g., HIPAA, False Claims Act, anti-Kickback Statute, Civil Monetary Penalty, etc.) impacting Medicare compliance to ensure Tufts Health Plan achieves and maintains full compliance with all applicable laws and regulations. * Project management skills. * Presentation and Writing Skills: Excellent writing and presentation skills required. Must be able to write and present highly complex regulatory information in a professional, clear and concise manner. * Demonstrated ability to establish relationships of trust and respect with staff at all levels throughout the company. * Highly proficient with Microsoft Office Applications, with particular focus on Microsoft Access and Excel. * Familiarity with data visualization software such as Tableau. * Strategic thinking and planning, process development and performance measurement skills. * Approaches challenges in a solution-oriented manner. * Takes the initiative to educate self about new requirements and guidance. * Self-motivated with the ability to manage, prioritize and complete multiple projects in a timely manner with limited supervision. WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS: (include special requirements, e.g., lifting, travel, overtime) CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Tufts Health Plan is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times. What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us! Please note: As of January 18, 2022, all employees - including remote employees - must be fully vaccinated. This position will require the successful candidate to show proof of full vaccination against COVID-19. Point32Health is an equal opportunity employer, and will consider reasonable accommodation to those individuals who are unable to be vaccinated consistent with federal, state, and local law. Tufts Health Plan Canton MA

Senior Contract Manager, Medicare

Point32health, Inc