Director, Managed Care

The Director of Managed Care provides strategic and operational leadership for provider relations, utilization nurse review, network and occupational sales, credentialing, enrollment and contracting. Reporting to the Vice President, Managed Care, this role is responsible for translating the organizations managed care strategy into successful contract negotiation, strong financial performance, effective contract administration, and productive payor, employer, broker and third-party administrator partnerships.

The Director partners closely with finance, revenue cycle, strategy, clinical operations, Beacon networks and other key stakeholders to ensure managed care agreements support the organizations financial, clinical and strategic objectives.  

Acts as a liaison with Centers for Medicare and Medicaid Services (CMS) and commercial insurance companies with respect to participation in value-based incentive programs. Supports the management team by providing input into the strategic planning process. Responsibilities also include the oversight of all managed care activities for the Community Health Alliance (CHA) and implementing guidelines for PHO (Physician Hospital Organization) physician credentialing and re-credentialing. Manages the Credentialing activities for CVO and Beacon Managed Care Provider Enrollment.

Responsible for managing all functions of the Accountable Care Organization (ACOs). Liaison with Centers for Medicare and Medicaid Services (CMS) to manage the MSSP Accountable Care Organization (ACO) contracts both internally and externally.

MISSION, VALUES and SERVICE GOALS

• MISSION: We deliver outstanding care, inspire health, and connect with heart.
• VALUES: Trust. Respect. Integrity. Compassion.
• SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

Directs all managed care activities for Community Health Alliance (CHA), Provider Enrollment and CHA ACO by:

• Developing short-and long-term goals and objectives consistent with the goals of CHA, Provider Enrollment/credentialing and CHA ACO; also developing an annual operating plan to encompass these functions. Also assisting and/or assuming responsibility for managed care strategic plan development.
• Managing criteria for managed care contracts for CHA with Provider Relations Manager.
• Analyzing current contracts (retrospectively) to determine profitability.
• Conducting house-wide educational programs related to CHA.
• Developing and maintaining a complete contract manual listing of all contracts, services, discounts and renewal dates for facilities and ancillary providers.
• Maintaining good working relationships with current employer clients and responding to all of their future requests and questions in a timely manner.
• Performing conflict resolution with representatives of current and new CHA managed care contracts. Also providing viable solutions which will maintain solid working relationships.
•  Ensuring the timely completion of initial and re-credentialing for all CHA, BMG and BHS contract providers by coordinating with outside credentialing agencies, regulatory agencies and contracted providers.
• Oversee the credentialing process and ensuring that policies and procedures are being followed.
• Managing and marketing CVO (Certified Verification Organization) services to local providers.
• Working with the credentialing software to make sure system is being used at the highest level and all appropriate information is reported.
• Reviewing and updating applications, operational policies/procedures and credentialing standards on a yearly basis, verifying all payer updates are incorporated into operational policies in accordance with National Committee on Quality Assurance (NCQA) credentialing guidelines
• Ensuring the timely completion of initial enrollment and re-credentialing for all BMG, BHS, Beacon Health LLC and any other Beacon Health System entity employed and contracted providers.
• Working closely with BMG to ensure the information provided to the governmental agencies is correct and complete, i.e. PECOS researching and staying up to date on all CAQH requirements and coordinating/communicating with the Beacon entities to ensure understanding and expectation.
• Ensure adherence to Delegated Credentialing agreements awarded to Beacon entities, tracking of audits etc., reporting submissions.
• Developing plans to enable Beacon to reach savings and quality performance targets on governmental and commercial value-based reimbursement contracts.
• Managing or assisting in the implementation of all new value-based reimbursement contracts, including bundled payments and opportunities from commercial insurance companies.
• Collaborates with departments involved in Beacon Care coordination and Quality Management functions.
• Works with other members of the management team on new product design.
• Manage relationship with Post-Acute Care network, ensuring proper communication, referrals and performance.
• Assists with the operational process of the Post-acute care network, care coordination, BMG quality, MSSP ACO, Commercial ACO, bundled payments and other value based contracts as appropriate.
• Researching mandatory or voluntary value-based reimbursement programs implemented by CMS, and ensuring that BHS entities are in compliance with the requirements of these programs.
• Ensuring all administrative requirements of current or future value-based reimbursement contracts are satisfied.
• Developing procedures to effectively manage and monitor Beacon’s strategy to succeed in value-based reimbursement contracts.

Directing the daily operational activities of the Managed Care Services Department and CHA associates by:¿

• Managing and scheduling the daily work load (and work flow) to ensure adequate staffing at all times and to achieve the highest level of productivity and efficiency.
• Recruiting, interviewing, hiring and evaluating (and, if necessary, coaching and disciplining) associates. Also ensuring that all new associates receive a comprehensive orientation.
• Providing ongoing guidance and assistance to the associates (for example, providing training regarding departmental policies, procedures and practices).
• Preparing and conducting performance reviews for the associates and providing feedback regarding job performance on an ongoing basis.
• Communicating with the associates on a regular basis to ensure they have the information regarding operational procedures that is necessary for effective job performance; also communicating procedural and informational changes relative to the functions of the department and CHA.
• Preparing an annual operating budget, which is subject to approval. Also monitoring the budget and controlling expenditures to ensure compliance.
• Communicating with the Executive Director regarding potential operational problems; also providing updates (as necessary) regarding the status and needs of the associates.
• Administering established departmental and Beacon Health System (BHS) policies, procedures and standards; also implementing new policies, procedures and standards.

Provides leadership for the ACO(s) and coordinates all functions with internal teams by:

• Serving as a key member of the ACO management team.
• Providing customer service support and acting as a liaison for BHS through communication, problem resolution and provider relations.
• Liaison with CMS to manage the CHA/ACO contract & with Caravan for TRH contract.
• Working with providers to ensure quality measures are implemented and reported to CMS within required timeframe.
• Developing plans to achieve evidence based medicine and patient engagement. 
• Working with established board committees.
• Developing and maintaining a communication and tracking methodology (for all BHS entities) for notification of ACO contracts. Serving as a liaison to the Finance Department (for example, regarding activities related to ACO contract management systems).
• Providing education regarding ACO contracts, and their requirements, to the employees of all BHS entities and non-Beacon participants. 
• Assisting other members of the management team with new product design.
• Serving as a “system administrator” for the department by maintaining up-to-date knowledge regarding ACO designs; also handles internal and external clients’ questions and problems.

Plans, coordinates, and manages ACO activities by:

• Reviewing and updating ACO applications, contracts, and operational policies/procedures on a yearly basis. 
• Collecting, analyzing and reporting information regarding specific providers.
• Handling the activities related to audits with payers.

Serves as ACO System Administrator by:

• Implementing reporting tools to assist in management of the ACO. 
• Coordinating and conducting training as needed for administrative staff. 
• Maintaining information on the intranet site.

Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department by:

• Completing other job-related duties and projects as assigned.

Leadership Competencies

• Drives Results - Consistently achieving results, even under tough circumstances.
• Customer Focus - Building strong customer relationships and delivering customer-centric solutions.
• Instills Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.
• Collaborates - Building partnerships and working collaboratively with others to meet shared objectives.
• Communicates Effectively - Developing and delivering multi-mode communications that convey a clear understanding of the unique needs of different audiences.

ORGANIZATIONAL RESPONSIBILITIES

Associate complies with the following organizational requirements:

• Attends and participates in department meetings and is accountable for all information shared.
• Completes mandatory education, annual competencies and department specific education within established timeframes.
• Completes annual employee health requirements within established timeframes.
• Maintains license/certification, registration in good standing throughout fiscal year.
• Direct patient care providers are required to maintain current BCLS (CPR) and other certifications as required by position/department.
• Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
• Adheres to regulatory agency requirements, survey process and compliance.
• Complies with established organization and department policies.
• Available to work overtime in addition to working additional or other shifts and schedules when required.

Education and Experience

• The above level of knowledge, skills and abilities are normally acquired through the successful completion of a Bachelor’s degree in Business, Economics, Marketing or a related field. A Master’s degree is preferred. Three to five years of managed care and group insurance experience through which a background in Medicaid, Medicare and physician contracting was gained is required. A minimum of two to three years of utilization review, case management and/or utilization management experience is required. A previous record of successful contract negotiation is required. Management/leadership experience is required.

Knowledge & Skills

• Demonstrates advanced knowledge of healthcare delivery systems (which includes PHO, HMO, PPO and POS); managed care products, services and systems; health benefit plans; hospital and physician relations; quality management and effective sales and marketing techniques.
• Requires in-depth knowledge of employee benefit products/plans, including: health/medical, dental, workers compensation and case processing (proposal, renewal, plan design, billing, claims, etc.).
• Demonstrates independent judgment, research and analytical skills necessary to develop programs, evaluate projects and approve (or recommend) changes in policies and procedures and the staffing levels that affect managed care and value based services.
• Requires well-developed knowledge and understanding of value-based reimbursement contracts, ACO, bundled payments, CMS, insurance industry and healthcare delivery systems; also requires an in-depth understanding of accounting and finance.
• Requires understanding of clinical quality metric requirements, such as those outlined in HEDIS guidelines.
• Requires a high level of interpersonal skills in order to ensure that effective relationships are developed, maintained and managed in a professional and effective manner with medical staff members, Hospital and System management team, patients, representatives of client organizations, business leaders, various public managers, physician groups and legal counsel.
• Demonstrates well-developed communication skills necessary to effectively communicate both verbally and in writing and to make presentations to individuals and small and large groups.
• Requires strong organizational and leadership skills necessary to effectively establish priorities, coordinate workloads, meet deadlines, and ensure effective functioning of the department.
• Demonstrates a willingness and ability to be flexible and adapt to changes in the overall healthcare environment or specific contractual obligations.
• Must be open to making continuous changes and improvements in established workflows to better accomplish quality goals.
• Demonstrates an advanced understanding of computer systems and proficiency in utilizing computer applications (i.e., word processing, spreadsheets and databases).
• Demonstrates the ability to gather and evaluate data and manage the effective utilization of resources (both staffing and financial); also includes math skills and the ability to prepare project plans and estimate costs.
• Requires knowledge of the requirements of regulatory and accreditation organizations.

Working Conditions

• Works in a hybrid environment. Some travel is required.
• May need to vary days and hours scheduled, as determined by the department's needs.

Physical Demands

• Requires physical ability and stamina to perform the essential functions of the position.

PI6cd8b8f2ff8b-37641-41720596