• 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 the level of underpayments and overpayments by providers.
• Creates and presents financial models for managed care contracts.
• Creates and delivers educational material regarding contracts and implications.
• Informs the CFO and Business Office Director of any reimbursement or regulatory requirements changes.
• Ensures all required strategic pricing, legal, reporting, and communication processes 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.
• Review 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.

Skills: Contract Management, Provider Enrollment, Payment Monitoring, Claims Processing, Financial Modeling, Regulatory Compliance, Educational Communication, Strategic Planning

• Manage all components of the contract negotiation process.
• Identify the key payors in new markets into which the Company enters.
• Lead the rate and language negotiation discussions with the payors.
• Work with the Company’s analytical resources and CFO to ensure negotiated rates are acceptable and will add value.
• Provide strategic leadership around negotiating contracts for closed networks.
• Work with Sales and Operations management to identify and implement contracting opportunities for revenue improvement.
• Develop productive and professional relationships with contracted payors.
• Works with the Company’s Billing Office when rates received by payors vary from the contract.
• Discuss/resolve claim issues resulting from contract interpretation and/or language.
• Meet regularly with the Business Office to discuss changes in payor policies affecting reimbursement or administration and any emerging payor concerns before incurring high-dollar losses.
• Keep abreast of marketplace changes for payors, networks, reimbursement issues, and changes in legislation or guidelines at the state and federal levels
• Ensure contract files are in order, kept up to date, and archived in compliance with records management policies and procedures.
• Identify and implement a payor contracts database software solution.
• Ensure all contracts are loaded into this solution.
• Distribute information about new contracts to key Company personnel.
• Provide tools and information to enhance the department’s Managed Care resources for contract language, reimbursement negotiation, and overall knowledge of managed care.

Skills: Contract Negotiation, Payor Identification, Rate Discussion, Strategic Leadership, Claims Resolution, Policy Monitoring, Relationship Management, Process Improvement

• Negotiate with external parties to pay rates that adequately meet Mercyhealth’s financial needs.
• Negotiate discussion on payment rate and structure, and all aspects of contract language.
• Provide and interpret decision support information for senior management of Mercyhealth, including department heads, physicians, and other clinicians.
• Develop short and long-term strategies and provide leadership for implementation plans regarding the overall direction of Mercyhealth, based upon priorities set by leadership
• Manage the design, implementation, and maintenance of the managed care information system
• Establish and maintain an effective system of contract administration to ensure the maximization of patient convenience and system end-user efficiency
• Provide senior management and staff with insights and knowledge to facilitate net revenue budgeting, long-term planning, and strategic planning of major hospital or clinical programs.
• Maintain current knowledge of community developments as they pertain to relevant managed care developments across the industry
• Participate in negotiations and oversee the implementation of Mercyhealth contracts
• Develop a marketable strategy for bundled pricing
• Establish and maintain stable working relationships with contracted and potential contracted entities
• Work with MercyHealth’s behavioral health, HHA, and Hospice providers to identify direct contracting and re-contracting opportunities
• Routinely analyze existing agreements to determine the viability of the agreement and the financial gain/risk of the arrangement.
• Maintain the underpayment division including education, root cause analysis, and reporting.
• Identify and target new areas for revenue growth
• Maintain active industry involvement with providers, payers, and managed care organizations

Skills: Contract Negotiation, Strategy Development, Decision Support, System Management, Revenue Planning, Market Analysis, Relationship Building, Financial Evaluation

• Plan, direct, and lead all activities of the Medicare and Medicaid programs, including oversight of the Complex Care Department
• Screen, interview, and hire clinical team employees, anticipating growth and training
• Monitor, develop, and recommend changes in operational procedures, monitor productivity and risk management, cost-effectiveness, staff engagement, performance, and satisfaction
• Identify educational needs and learning styles to develop care management tools through collaboration with various operational staff
• Collaborate with Quality Management and Care Management to implement effective methods to optimize access to preventive care screenings and disease management for members
• Participates in departmental audits conducted by CPHL internally, the Department of Health, the Centers for Medicaid and Medicare, and other entities.
• Participate and lead clinical rounds or case conferences, and provide clinical solutions that may include access to care for members, discharge planning, member education, and coordination of care
• Actively work with the Utilization Management Department to ensure that the member has a needs-based level of services that are available and delivered in a timely, cost-effective manner based upon any relevant change in the member’s condition
• Work with senior management and leadership to develop models of care, identify issues, and develop solutions for the Medicaid-Medicare and Medicare programs
• Assure Complex Care Department’s activities remain compliant with all regulatory, contractual, and internal standards and requirements
• Collaborate across a matrixed team of revenue cycle, legal, and administrative resources and possess executive-level visibility.
• Develop and maintain a deep understanding of state and federal legislation related to payment initiatives and policy changes.

Skills: Program Oversight, Staff Management, Operational Improvement, Care Coordination, Quality Management, Clinical Leadership, Regulatory Compliance, Reimbursement Strategy

• Provide day-to-day leadership and management of regional payor relations and reimbursement that mirrors the adopted mission and core values of the company.
• Counter the pay or objections by clearly articulating the company’s position through written correspondence.
• Responsible for understanding the medical policy landscape of the territory and developing an action plan to overcome any negative medical policy positions.
• Know the payor reimbursement models required to successfully overcome payment objections.
• Review a negative medical policy, and develop an action plan for successfully overcoming objections.
• Responsible for collaborating with senior and commercial management to drive the company reimbursement strategy to achieve and surpass sales, profitability, cash flow, and business goals and objectives.
• Provide timely, accurate, and complete reports on the reimbursement status of regional payor targets.
• Spearhead the development, communication, and implementation of positive payor medical policies and contracts both internally and externally.
• Plan, develop, organize, implement, direct, and evaluate the region’s reimbursement function and performance.
• Participate in the development of the corporation's plans and programs as a strategic partner.
• Enhance and/or develop, implement, and enforce policies and procedures of the organization by way of systems that will improve the overall operation and effectiveness of the corporation.
• Establish credibility throughout the organization and with senior management as an effective developer of solutions to business challenges.
• Collaborate with the senior management team to develop and implement plans for the operational infrastructure of reimbursement systems, processes, and personnel designed to accommodate the rapid growth objectives of the organization.
• Act as an advisor from a financial perspective on any payor contracts into which the Corporation may enter.

Skills: Payor Relations, Reimbursement Strategy, Objection Handling, Medical Policy Analysis, Reimbursement Models, Technology Assessment, Strategic Collaboration, Policy Development

• Experience in a medical group setting or healthcare consulting, especially in Managed Care
• Experience working with network management or contracting departments within Medical Groups or Care Delivery Organizations
• Managed Care working experience
• Knowledge and experience in network and contracting within regional medical groups
• Ability to support and manage medium-sized project teams, inclusive of operators, vendors, and analysts across remote locations
• Ability to quickly build meaningful relationships with key stakeholders
• Strong negotiating skills and a solid understanding of payer contracts
• Ability to travel both locally and overnight when needed
• Ability to build relationships with providers, external vendors/payers, and employees at all levels in the organization
• Strong communication skills, both verbal and written, as well as an ability to present information effectively to a senior-level audience
• Ability to analyze and interpret data and solve practical problems.

Qualifications: BA in Health Administration with 4 years of Experience

• Strong analytical and interpretive skills
• Strong organizational skills
• Excellent interpersonal and negotiation skills
• Ability to work in a team environment
• Ability to meet or exceed Performance Competencies
• Experience with State and external accreditation, managed care audits, and reviews
• Prior experience developing and leading nurse case management, medical director, and clinical teams
• Demonstrated results in developing strategic plans and executing key initiatives
• Ability to collaborate across functional lines and leaders
• Strong communication and analytical skills
• Certification in case management, pharmacy, rehabilitation nursing, or a related specialty
• Related experience or equivalent combination of education 
• Direct nurse management experience.

Qualifications: BS in Management Information Systems with 5 years of Experience

• Financial analysis and negotiation skills
• Moderate to Advanced Excel Skills
• Knowledge of the Managed Care environment
• Familiarity with Physician/Payer contract language
• Strong communication and organization  skills
• Experience in account management and healthcare sales
• Experience with CPT-Code reimbursement
• Previous experience with independent home office work
• Previous experience with bringing new products to the healthcare market
• Knowledge of CMS, third-party payor requirements, prior authorizations, claims adjudication, and medical policy review.
• Proficient in working with Microsoft Office, specifically MS Excel and PowerPoint.
• Must be able to handle a wide variety and work in a fast-paced environment.
• Must be a detail-oriented, organized self-starter, and have the ability to prioritize workload.

Qualifications: BA in Healthcare Management with 6 years of Experience

• Knowledge of pharmaceuticals used to treat pain
• Knowledge of behavioral health
• Knowledge of the pain management process
• Knowledge of the drug rehabilitation process
• Knowledge of workers' compensation laws and regulations
• Excellent oral and written communication,
• Ability to prepare presentation documents and present them to senior leadership
• Advanced computer skills to include Microsoft Products
• Proven ability to manage organizational change, to involve and influence others to accept new ideas or innovative approaches, lead in a team-based organization
• Ability to manage a diverse team, including clinical professionals in multiple locations
• Ability to develop reports, metrics, and improvement plans
• Ability to interact collaboratively and work effectively with a multi-functional team and throughout the organization fosters an environment of shared responsibility and accountability
• Experience applying medical management treatment guidelines
• Experience with writing and implementing program-level policy and procedures

Qualifications: BA in Public Health with 7 years of Experience

• Excellent knowledge and command of clinical trial design and methodology, observational study designs, epidemiology, biostatistics, value frameworks, and health economic principles
• Demonstrated business acumen, with the ability to simplify complex topics to drive decision-making
• Demonstrated leadership skills and ability to work across multiple products
• Ability to multi-task and manage several account plans and needs, internal/external deadlines, with a strong sense of urgency
• Excellent written and verbal communication skills and ability to articulate and defend the full clinical value proposition for assigned brands
• Able to work independently in a home office environment (without interruptions or significant distractions during normal business hours)
• Experienced in account planning with the ability to effectively work alongside commercial and other functions to develop robust account plans which include.
• Understanding of the pharmaceutical industry regulatory and compliance environment, history of operating with ethics and integrity
• Knowledge of community long-term care, current community health practices for the frail adult population, and appropriate support services in the community
• Knowledge of Medicaid-Medicare and Medicare programs
• Clinical experience with experience in staff supervision and program management
• Experience working within community-based home health organizations
• Experience working within a managed care environment

Qualifications: BA in Business Administration with 9 years of Experience