Job Summary: 

• In collaboration with executive leadership, develop MLKCH’s managed care and contract strategy for all products (Medi-Cal, Medicare, etc.) and all markets and service area segments
• As appropriate, develop and review all MLKCH health plan contracts. 
• Negotiate all contract aspects, terms, and deal points including reimbursement/ compensation, utilization, authorization, and operational management. Includes Medi-Cal Managed Care, Medicare Advantage (HMO), and Commercial PPO and HMO.
• Work closely with MLKCH Revenue Cycle, Business Development, Quality Management, and Executive Leadership, and Medical Administration teams to develop, cultivate, and maintain positive and effective working relationships with all partner ambulatory/ physician/ IPA organizations in the MLKCH Service Area
• Work closely with MLKCH Revenue Cycle, Business Development, Quality Management, and Executive Leadership, and Medical Administration teams to implement health plan contracts from an operational and financial perspective
• Work closely with MLKCH contracted hospital-based physician providers to facilitate contracting and network relationships with key health plans and IPA’s. 
• Work with MLKCH’s physician billing provider (CHMB) and partner managed care IPA’s and to facilitate billing and collection of MLKCH-guaranteed hospital-based physician payments.
• Through associates and subordinates, monitor and review the financial, quality, and operational impact of all health plan contracts. 
• Using data analytics, prepare renegotiation strategy and tactics for all health plan contracts.
• Serve as a consulting/ analytical/ strategic resource to MLKCH executive leadership and middle management on managed care contract issues such as profitability, operational issues, quality, etc.
• Using data analytics through subordinates and associates, periodically report on health plan contract patient volume, profitability, demographics, quality outcomes, and other key metrics

Skills on Resume: 

• Contract Strategy (Hard Skills)
• Negotiation (Hard Skills)
• Relationship Management (Soft Skills)
• Operational Implementation (Hard Skills)
• Billing Coordination (Hard Skills)
• Data Analytics (Hard Skills)
• Strategic Consulting (Soft Skills)
• Collaboration (Soft Skills)

Job Summary: 

• Serves as a member of RHG managed care committees at both RHG-New Jersey Medical School (NJMS) and RHG Robert Wood Johnson Medical School (RWJMS), provides support and seeks consistent guidance from committee members regarding strategic direction and priorities.
• Fosters professional relationships with private and public payor management representatives and serves as the principal liaison between RHG and payors regarding contract changes and dispute resolution.
• Works in close collaboration with respective practice division leadership and RHG leadership to ensure that the needs of each practice division are being met while balancing the overall demands of RHG as an integrated practice.
• Represents the interests of RHG in managed care related discussions with affiliated health systems 
• Fosters relationships with RHG department chairs and faculty, clinical administrators, and other RHG and Rutgers Biomedical and Health Sciences (RBHS) executives.
• Collaborates with RHG and practice division leadership to identify contracting strategy and expansion opportunities (e.g., through the development of new payor relationships, entrance into new markets, participation in new and/or innovative insurance products), including development of managed care contracting strategy across units as appropriate and desirable.
• Supports the development of managed care strategies and initiatives for RHG to lead and adapt to ongoing healthcare payment reforms and evolving payment methodologies, including ACOs and CINs.
• Facilitates RHG involvement in defining the future payment/incentive model for the New Jersey Medicaid Access to Physician Services (NJ MAPS) program.
• Remains abreast of local, regional, and national developments pertaining to managed care and advises leadership on implications and recommended actions.
• Defines contract negotiation objectives in coordination with the Senior Vice Chancellor, Senior Associate Dean, and CFO of Combined Medical Group, as well as practice division leadership, including opportunities to incorporate new technologies, procedures, and changes in the market.
• Manages and supports analytical staff in maintaining a detailed utilization database, including utilization and payment information by code, specialty, and payor benchmarked against Medicare and other payment rates and contractual net financial performance.
• Directs analytical resources to quantify the impact of alternative proposals before and during negotiations as well as post contract execution to ensure contract compliance.

Skills on Resume: 

• Strategy (Soft Skills)
• Relationships (Soft Skills)
• Conflict Resolution (Soft Skills)
• Collaboration (Soft Skills)
• Market Expansion (Hard Skills)
• Payment Reform (Hard Skills)
• Policy Development (Hard Skills)
• Leadership Support (Soft Skills)

Job Summary: 

• Leads contract negotiations with payors guided by RHG's contracting priorities and informed by analysis.
• Negotiates contract language and facilitates review from legal counsel.
• Oversees monitoring of contract anniversary dates, reporting, and notification requirements, and ensures annual rates are implemented correctly and on time.
• Working in coordination with practice divisions and other managed care staff, ensures that RHG has the capability to track and report performance under any value-based or other pay-for-performance initiatives.
• Oversees and/or coordinates the collection, validation, and reporting of NJ MAPS data for the RHG practice divisions to the state.
• Develops and maintains appropriate policies, procedures, and controls for managed care and payor contracting activity.
• Monitors health plans adherence to contract terms, identifies and resolves contractual disputes with payors in a timely, organized manner and in coordination with practice division revenue cycle and other staff.
• Directs and manages assigned staff, including training, orientation, and counseling.
• Works with the Senior Associate Dean to instill, maintain, and enhance in employees the vision, mission, and values of the University, RBHS, and RHG. 
• Heightens employee morale via open lines of communication, fair and equitable treatment, and annual evaluations of all employees.
• Selects, trains, directs, and evaluates the performance of and, when necessary, disciplines and discharges direct report personnel. 
• Assists subordinates with difficult employee relations problems
• Understands and adheres to the University's compliance standards as appear in the RBHS Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy.

Skills on Resume: 

• Contract Negotiation (Hard Skills)
• Legal Review Coordination (Hard Skills)
• Project Management (Hard Skills)
• Performance Tracking (Soft Skills)
• Data Validation and Reporting (Hard Skills)
• Policy Development (Hard Skills)
• Conflict Resolution (Soft Skills)
• Team Leadership (Soft Skills)

Job Summary: 

• Oversee the strategic development of Managed Care, IPA, and Payor Contracts on a national, regional, and local level for multiple lines of business including commercial and governmental products.
• Provide support and expertise to contract managers in developing and analyzing large and complex data sets for the creation of financial rate models, make proposal recommendations in negotiating/renegotiating and implementing rates and terms for health plan contracts, ensuring key operational and financial budget objectives are met.
• Lead, develop and identify negotiation strategies for value based contract negotiations with payors, while working collaboratively with internal key stake holders to execute and manage such arrangements.
• Review and evaluate contract language and reimbursement terms in existing and potential managed care agreements, and make recommendations and execute any modifications required for the benefit of the organization.
• Cultivate relationships and maintain strong communications with health plans and payor contacts.
• Prepare financial reports to review and assess utilization trends and overall financial performance of contracts, and identify improvement opportunities with rates/contract language, with the development of action plans to carry out improvements.
• Establish performance expectations and provide staff coaching to achieve positive results. 
• Recognize effective performance, and address performance needing improvement in an honest and timely manner.
• Secure support for negotiation goals and positions with both internal and external constituents through strong and effective persuasive skills and technical knowledge.
• Monitor, interpret, evaluate and report on changes in payor performance, market trends, health care delivery systems, and legislative initiatives that impact managed care efforts and provide recommendations to adapt to a changing health care industry.
• Develop professional relationships with contracted payers. 
• Works with the Company's Billing Department as needed to discuss/resolve claim issues resulting from contract interpretation and/or language
• Monitoring changes in payer policies affecting reimbursement or administration and any emerging payer concerns. 
• Keeping up-to-date on marketplace changes for payers, networks, reimbursement issues and changes in guidelines
• Oversee the process of health plan enrollment/credentialing applications for facilities and licensed providers with all health plans. 
• Ensure that all payer contracts are renewed prior to expiration

Skills on Resume: 

• Strategic Contract Management (Hard Skills)
• Data Analysis (Hard Skills)
• Negotiation Strategy (Soft Skills)
• Contract Evaluation (Hard Skills)
• Relationship Building (Soft Skills)
• Financial Reporting (Hard Skills)
• Leadership and Coaching (Soft Skills)
• Market Trend Analysis (Hard Skills)

Job Summary: 

• Manages third party payer contracts and Provider Enrollment and keeps files up to date.
• Coordinates negotiation and implementation of commercial contracts and payers.
• Monitors and communicates changes in payment schedules, reimbursements, and expiration dates of third-party payer contracts.
• Monitors the performance of managed care contracts to ensure accurate claims processing including level of underpayments and overpayments by providers.
• Creates and presents financial models pertaining to managed care contracts.
• Creates and delivers education material regarding contracts and implications.
• Informs CFO and Business Office Director of any changes in reimbursement or regulatory requirements.
• Ensures all required processes related to strategic pricing, legal, reporting and communication are deployed to maximize contract performance and yield.
• Completes applications for payer contracts and analyzes contract offers from payers to ensure offerings are competitive within the market.
• Reviews contract language for financial, legal and operational impact and to ensure compliance with State and Federal Regulatory Agencies.
• Ensures billing practices are within compliance by staying up to date on changes within the managed care market.
• Recommends new strategic managed care opportunities to the CFO.
• Develops and administers the managed care contracts for the facility by working closely with clinicians and processing referrals.
• Managing all components of the contract negotiation process. Identifying the key payers in new markets into which the Company enters
• Lead the rate and language negotiation discussions with the payers
• Work with the Executive Director and Director of Finance to ensure negotiated rates are acceptable and will add value

Skills on Resume: 

• Contract Management (Hard Skills)
• Negotiation (Hard Skills)
• Claims Processing Oversight (Hard Skills)
• Financial Modeling (Hard Skills)
• Education and Training (Soft Skills)
• Regulatory Compliance (Hard Skills)
• Market Analysis (Soft Skills)
• Strategic Planning (Soft Skills)

Job Summary: 

• Pitch and sell company services utilizing a structured sales process
• Effectively work with healthcare professionals, institutions, community agencies, trade associations, and manufacturers to promote the company's value proposition
• Solicit, negotiate, implement, and maintain long-term referral generating relationships
• Convert current and new customer sources into a progressively growing referral and revenue base
• Maintain customer relations, identify issues, and develop creative solutions
• Organize and prioritize time and schedules to maximize exposure to key customers
• Attend trade shows, conferences, association meetings, and educational seminars
• Coordinates and manages the social service process
• Supervise the growth standards to provide care and manage clinical operations
• Managing budget of operations and financials
• Helping to develop and recommend policies
• Participates in executive team forum
• Develop processes to screen, interview, hire, train, and department staff
• Ensures compliance with administrative, legal and regulatory requirements of the Health Plan contract and governmental and accrediting agencies.

Skills on Resume: 

• Sales Strategy (Hard Skills)
• Relationship Building (Soft Skills)
• Negotiation (Hard Skills)
• Customer Conversion (Soft Skills)
• Time Management (Soft Skills)
• Event Participation (Soft Skills)
• Budget Management (Hard Skills)
• Regulatory Compliance (Hard Skills)

Job Summary: 

• Oversee the DCE (Direct Contracting Entities), MA (Medicare Advantage) plan, Care Management and Credentialing Departments
• Responsible for administrative contracting, delegation, and the day-to-day management and operations of the organization, including oversight of claims payment, enrollment processing and member service operations, grievance and appeal operations, pharmacy management, analytics, information technology, revenue management, and compliance monitoring and auditing.
• Directs intra- and inter-departmental activities related to implementation of internal business operational processes, as well as ongoing management of information system maintenance, enhancements, new software releases, and interfaces.
• Responsible for the design, maintenance, and improvement/reengineering of business structure, business workflow processes, and/or configuration and integrity of computer programs/systems supporting business operations.
• Serve as an internal consultant on matters relating to decision support, data analysis and system functionality, assisting in optimizing relations with vendors and providers.
• Routinely identify trends and inform the CEO of sensitive issues and/or problem areas in the plan’s dealing with vendors or providers. 
• Recommend and implement corrective actions 
• Assist in the negotiation of vendor contracts.
• Oversee the Director of Network Management’s provider contracting activities and network optimization.
• Schedule and conduct meetings with Committees of the Board of Directors as specified and necessary.

Skills on Resume: 

• Operations Management (Hard Skills)
• Contract Management (Hard Skills)
• Team Leadership (Soft Skills)
• Process Improvement (Hard Skills)
• Data Analysis (Hard Skills)
• Compliance Monitoring (Hard Skills)
• Vendor Relations (Soft Skills)
• Problem Solving (Soft Skills)

Job Summary: 

• Direct the workforce to meet strategic goals as determined by the CEO and approved by the Board of Directors.
• Manage and evaluate employees directly reporting
• Plan, develop, and implement annual business strategy plans. 
• Report to the CEO and Board of Directors on a regular basis the progress of said business plans.
• Participate as necessary in marketing presentations and/or customer meetings.
• In conjunction with the Chief Medical Officer (CMO), review, analyze, and monitor the cost effectiveness of utilization programs/services.
• Manage all government relations and public relations activities in collaboration with the Compliance Officer.
• DMC meets with the Director of Marketing and Sales as needed to increase revenue and enrollment and achieve financial performance targets.
• Assist the CEO in negotiating and implementing contracts with the State and other entities.
• Represent the CEO as necessary at various trade association and industry meetings.

Skills on Resume: 

• Strategic Planning (Hard Skills)
• Employee Management (Soft Skills)
• Business Development (Hard Skills)
• Reporting and Communication (Soft Skills)
• Marketing and Presentation (Soft Skills)
• Cost Analysis (Hard Skills)
• Public Relations (Soft Skills)
• Contract Negotiation (Hard Skills)

Job Summary: 

• Develop the plan and implement strategies for payer engagement, contract management and negotiations.
• Assess and make recommendations to improve the efficiency of the current process for contract development and implementation
• Keep abreast and disseminate pertinent regulatory and insurance-related information in order
• Promote timely and efficient billing of all inpatient, outpatient, and ancillary services
• Build and maintain relationships with key Third Party stakeholders
• Enable strong negotiating results and optimal payer revenue growth
• Negotiate contract agreements/reimbursement rates
• Provide proactive and responsive communication to payers, senior leadership and administrators
• Analyze and review monthly results for risk against annual plan and forecast projections, providing variance explanations/recommendations
• Provide financial support in the completion of monthly system reporting
• Provide servant leadership to a team of dedicated professionals
• Contribute to the continued success and growth of the function and organization
• Provide mentoring for career development.

Skills on Resume:

• Analysis (Soft Skills)
• Contract Management (Hard Skills)
• Negotiation (Hard Skills)
• Process Improvement (Hard Skills)
• Relationship Building (Soft Skills)
• Leadership (Soft Skills)
• Regulatory Knowledge (Hard Skills)
• Financial Reporting (Hard Skills)