WHAT DOES A DIRECTOR OF MANAGED CARE DO?
Updated: Mai 27, 2025 - The Director of Managed Care analyzes financial and claims data to drive successful contract negotiations and payer strategies. Develops and presents financial models to monitor portfolio performance and market trends. Builds strong relationships with payers, clients, and internal teams to ensure contract efficiency and client satisfaction.
A Review of Professional Skills and Functions for Director of Managed Care
1. Director of Managed Care Duties
- Portfolio Management: Oversee the regionally based Managed Care portfolio for AMSURG.
- Contract Negotiation: Negotiate contractual and reimbursement terms with market payors.
- Payment Reform Analysis: Evaluate and address risks and opportunities related to payment reform, bundled payments, value-based payments, and alternative payors.
- Strategic Visits: Conduct onsite visits with payers, clients, and centers requiring market-specific strategies.
- Data Analysis: Analyze claims trend data and market information to support contract negotiations.
- Financial Review: Review and present financial data, utilization trends, and patient mix for contract negotiation and re-negotiation.
- Performance Monitoring: Prepare financial reports, models, and presentations to track portfolio performance and payor metrics.
- Market Knowledge: Maintain up-to-date knowledge of payer products, enrollment statistics, and trends.
- Business Development: Support forecasting for acquisitions and divestitures.
- Relationship Building: Create and maintain relationships between operations, clients, and payors related to contract performance.
- Issue Monitoring: Foster inter-company relationships to address provider participation, contract loading, and payment issues.
- Client Communication: Maintain client satisfaction through consistent internal and external communication.
- Goal Execution: Assist in setting departmental goals and execute projects to monitor performance.
- Corporate Initiative Leadership: Lead communication and execution of corporate initiatives.
- Matrix Collaboration: Work effectively in a matrix environment with competing customer demands.
- Information Security: Adhere to Information Security Policies to ensure organizational security.
2. Director of Managed Care Details
- Strategy Development: Develop a Managed Care Strategy for the Beltone Network with the VP of Business Operations
- Sales Growth: Drive hearing benefits and device sales penetration and growth through MCOs
- Relationship Management: Develop and expand relationships with MCOs to grow sales revenue
- Offering Design: Design managed care offerings that are attractive and will be embraced by provider network
- Strategic Targeting: Identify, target, and maintain strategic relationships with MCOs with the goal of establishing mutually beneficial relationships
- Sales Process Leadership: Direct entire MCO sales and account management processes including prospecting, qualifying, contracting, and expanding relationships using a consultative approach
- Marketing Coordination: Coordinate marketing programs with MCOs to membership including direct mailings, newsletters, online presence, emails, social media, print advertising and insurance directories
- Account Planning: Create annual plan for strategic accounts working with Managed Care and Sales teams to communicate product changes, pricing, program changes, new accounts and terminated accounts
- Data Management: Maintain accurate program information for strategic accounts
- Reporting: Generate ad hoc reports and general reporting through Excel, BI, Salesforce, and Navision
- Cross-Functional Collaboration: Partner with Sales, Marketing, Legal, and Finance teams to meet account performance objectives and expectations
- Technical Expertise: Serve as the technical resource/expert within organization on strategic accounts
- Market Awareness: Maintain awareness of marketplace trends that affect industry as well as legal, political, and regulatory trends
- Trade Show Engagement: Attend healthcare trade shows to generate leads and increase awareness of hearing devices and care programs
- Unified Messaging: Participate with Sales and Marketing to ensure a single consistent company and market message
- Provider Support: Support provider network by simplifying and improving provider experience
3. Director of Managed Care Responsibilities
- Contract Management: Manage all components of the contract negotiation process.
- Payor Identification: Identify the key payors in new markets into which the Company enters.
- Rate Negotiation: Lead the rate and language negotiation discussions with the payors.
- Strategic Leadership: Provide strategic leadership around negotiating contracts for closed networks.
- Revenue Improvement: Work with Sales and Operations management to identify and implement contracting opportunities for revenue improvement.
- Payor Relationships: Develop productive and professional relationships with contracted payors.
- Claim Issue Resolution: Work with the Company’s Billing Office to resolve claim issues resulting from contract interpretation and/or language.
- Policy Monitoring: Meet regularly with the Business Office to discuss payor policy changes affecting reimbursement or administration.
- Market Awareness: Keep abreast of marketplace changes, reimbursement issues, and changes in legislation at state and federal levels.
- Records Management: Ensure contract files are in order, updated, and archived in compliance with records management policies.
- Database Implementation: Identify and implement a payor contracts database software solution with the CFO.
- Contract Distribution: Distribute information about new contracts to key Company personnel.
- Resource Enhancement: Provide tools and information to enhance Managed Care resources for negotiation and knowledge-building.
- Process Efficiency: Evolve department processes to promote greater efficiency.
- Credentialing Oversight: Oversee health plan enrollment/credentialing applications for facilities and providers.
- Progress Tracking: Review weekly reports from the credentialing database to ensure prioritized follow-ups and accurate records.
- Contract Renewal: Ensure all payor contracts are renewed prior to expiration.
- Policy Compliance: Maintain compliance with all Company policies and procedures.
4. Director of Managed Care Accountabilities
- Relationship Management: Support relationships between healthcare payers and the IPA and resolve issues related to credentialing, managed care participation, claims payment, demographic changes, referrals, and accessibility.
- Contract Analysis: Analyze all managed care contracting, including value-based contracts, deliverables, working collaboratively with the Director of Population Health.
- Network Management: Manage and maintain accurate network files for each pending and executed managed care contract and provide network updates to payers, working with IPA providers to confirm the accuracy of reports.
- Application Support: Support and track the development and submission of applications for new managed care contracts and value-based initiatives, obtaining stakeholder and governance input and providing oversight on deliverables.
- Performance Reporting: Review reports provided by payers on financial and quality performance, develop summary reports for IPA leadership, and flag areas of concern.
- Risk Distribution: Collaborate with IPA analytics and finance teams to design and distribute risk/shared savings among network participants in various VBP programs.
- Implementation Initiatives: Define critical implementation or performance improvement initiatives for managed care contracting and VBP programs and support the implementation process within the IPA.
- Data Analysis: Analyze network adequacy and network leakage data, identifying opportunities for continuous improvement across the clinically integrated network.
- Report Development: Develop written and verbal reports on managed care contracting, VBP, sustainability, and clinical integration.
- Provider Assistance: Assist providers with initiatives related to EDI, access and availability, quality compliance with HEDIS, and electronic medical record conversions.
- Negotiation Expertise: Demonstrate a proven track record in achieving results in challenging environments, including contract and dispute resolution negotiations.
- Healthcare Knowledge: Possess a strong understanding of the healthcare industry, payor-provider reimbursement methodologies, and pricing strategies.
- Policy Understanding: Develop and maintain a deep understanding of state and federal legislation related to payment initiatives and policy changes.
- Contract Standards: Establish consistent organizational standards for contract structure and terms.
- Team Leadership: Lead, manage, and develop the team.
5. Director of Managed Care Contracts Functions
- Contract Management: Manage both an internal contracts administrator and multiple outside resources to maintain existing contracts (200) and develop new key payers (50+).
- Compliance Assurance: Ensure that the organization's contracts are administered appropriately in accordance with state, federal, and payer requirements.
- Cross-Functional Collaboration: Work proactively with reimbursement and sales/marketing staff to promote strong payer relationships.
- Strategic Leadership: Act as the lead strategist, negotiator, and contact person for relationships with existing and new payers.
- Growth Strategy: Provide strategies to engage key payer providers at a deeper level, creating a competitive advantage for sales.
- Reimbursement Coordination: Work closely with the reimbursement department on changes with existing contracted payers.
- Issue Identification: Determine key issues to increasing coverage with payers.
- Process Development: Build processes and capabilities to support business decisions.
- Contract Negotiation: Review and negotiate all Managed Care Contracts.
- Market Awareness: Maintain up-to-date knowledge of payer and reimbursement trends in the market.
- Risk Evaluation: Evaluate Medicare and Medicaid reimbursement rates to determine risk levels and opportunities.
- Financial Reporting: Ensure financial information is presented accurately and in a timely manner.
- Budget Support: Assist with budgets, forecasts, and the month-end closing process.