Director Managed Care Resume Samples

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L Veum

Lea

Veum

5953 Fadel Spur

San Francisco

+1 (555) 468 9743

5953 Fadel Spur

San Francisco

Phone

p +1 (555) 468 9743

Experience Experience

New York, NY

Director Managed Care

New York, NY

Klein, Botsford and Moore

New York, NY

Director Managed Care

Coordinate with CDM around strategic pricing & coding for contract optimization
Supervision, training and coaching of the assigned personnel
Extensive knowledge of PBMs and Managed Care Contracting
Creates and communicates financial and risk terms with internal and external leadership including high-level hospital administrators and physician leaders
Effectively communicates Managed Care positioning both internally and externally to support business development, contract implementation and growth strategies
Leads on-going negotiations and subsequent implementation and maintenance of contracts for the North American and Respiratory Care divisions
Maintains current working knowledge of Federal Government Acquisition and state acquisition rules

Phoenix, AZ

Director, Managed Care

Phoenix, AZ

Bahringer-Nolan

Phoenix, AZ

Director, Managed Care

Perform periodic and specific reviews of volume and pricing in an effort to maximize contract performance and continuous improvement
Works collaboratively with Patient Care Coordination (PCC) to ensure that contracts can be administered from a Utilization Management perspective
Networks with payers, providers, brokers, and others throughout the region in order to build and maintain market knowledge and market direction
On-going monitoring of financial performance of the managed care agreements
Renegotiation of hospital and/or physician managed care agreements in accordance with the Contracting Plan developed each fiscal year
Improve overall Managed Care integration into the Piedmont organization through effective communication and implementing strategic initiatives
Manages the day-to-day Managed Care operations and contracting activities

present

New York, NY

Director, Managed Care Contracting

New York, NY

Treutel-Hudson

present

New York, NY

Director, Managed Care Contracting

present

Oversees and participates in the development, negotiation, implementation, monitoring and management of all assigned managed care agreements
Assembles information and prepares materials for presentation to committees, administrators and managed care networks
Facilitates promotion of departmental programs to provider networks
Develop strategies to link payment to performance and quality of the practices
Liaison with physician practices, hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
Work with the IRM Analytics Group to establish negotiating position
Perform special projects as requested by the Vice President of Managed Care

Education Education

Bachelor’s Degree in Business

Columbia University

Bachelor’s Degree in Business

Skills Skills

Software/Hardware: Strong knowledge in Microsoft Office applications – Word, Excel, Access, and PowerPoint; proven ability to learn new information systems as necessary
Experience (Type & Length): At least ten years as a leader in a managed care environment of a similar capacity including negotiating a wide range of performance based arrangements. Management / supervisor experience highly recommended
Knowledge of Managed Care environment
Ability to work both independently and within a team environment and a multi-dimensional environment
Ability to function effectively within an ever-changing environment and to meet deadlines and reprioritize as necessary
Strong organizational and project management skills including development of project parameters, goals, and timelines as well as outcome measurement
Ability to present information to small and, at times, large audiences of various skill levels
Proven excellent written and verbal communication skills
Develop and execute communication plans to internal and external stakeholders related to payer relationships, negotiations, organizational contractual obligations, and developments in the managed care marketplace
Coordinate financial analysis of payer contract performance and modeling projections based on alternate contract agreements with payers, adverse trends, etc., and make appropriate recommendations or conclusions

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Regional Director Managed Care Resume Examples & Samples

Functions as an independent member of a cross functional team to support the development of new MSH programs and expansion into new opportunities and support of new initiatives
Performs consulting services in support of our partners’ “Clients” business objectives
Assists in the development and recruitment of new partners; performs thorough review of Business operations that relate to Managed care and payer strategies
Consults with practice management and managed care on the development of market and payer specific strategies and tactics
Facilitate the resolution of problem payer issues utilizing personal contacts, negotiations and skills
Ensures development, implementation and maintenance of managed care policies, procedures and objectives and ensures their adequate execution and compliance by consulting with, educating, and training practice management and staff as needed
Working in coordination with the “Clients”, assists in the recruitment, hiring, and training functions and establishing an action plan for staff
Supports local, regional and corporate contract administration initiatives by soliciting, integrating, and distributing data and communications on managed care issues. Provides all documentation required to coordinate a consistent corporate response to network requests for bids and quotes
Ensures all managed care contracts are negotiated in accordance with budgetary objectives to maximize benefit to the company through consultation or direct negotiation
Ensures accurate profitability analyses are conducted using current pricing and utilization on all managed care bids, quotes and approved unique billing arrangements
Maintains tracking of all MC contracting initiatives across the specialty/Business Unit and prepares summary reports as requested
Maintains awareness of managed care trends, competitive managed care activities and market developments and recommends, implements and administers related responses
This can be a remote based position when not traveling
Extensive experience negotiating managed care contracts with payers/insurance companies on behalf of providers
Ensuring all managed care contracts are negotiated in accordance with budgetary objectives to maximize benefit to the company through consultation or direct negotiation
Experience in managed care contracting strategies including value-based reimbursement, preferred provider strategies, and positioning centers of excellence with payers
Experience ensuring accurate profitability analyses are conducted using current pricing and utilization on all managed care bids, quotes and approved unique billing arrangements
Prior consulting experience with practice management and managed care on the development of market and payer specific strategies and tactics
Ability to assist in the development and recruitment of new partners; performs thorough review of Business operations that relate to Managed care and payer strategies
Proficiency with analytical tools, Excel, PowerPoint, MS Project, MS Access, Salesforce.com
Experience with Oncology, Radiation, or Surgery specialties, highly desired

Medical Director, / Managed Care Services Resume Examples & Samples

Assists in providing leadership, direction, and oversight for all managed care clinical operations including Utilization Review, Quality Oversight, and Special Referral Management
Provides clinical leadership and oversight to the Utilization Management and Quality Oversight teams responsible for concurrent review and retrospective review for hospital admissions, prior authorizations for select services, pharmacy case reviews, care coordination, nurse advice line, denial processes, member clinical appeals, regulatory compliance, quality management, provider credentialing and re-credentialing, health education and culture, and linguistic functions for DHS and Community Partners to comply with contract requirements and State Department of Health Care Services regulatory criteria
Assists in strategic planning and transformation of Managed Care Services so that it services as a management services organization for DHS' entire health care delivery system
Assists in setting manage care priorities for DHS' health care delivery system
Ensures consistency of and adherence to managed care clinical standards across the DHS health care delivery system
Assess and monitors capacity within the DHS health care delivery system to ensure compliance with access to care standards and requirements across the continuum of services
Meets regularly with leadership in the County's hospitals and ambulatory clinics to assure identification and resolution of managed care and operational issues and priorities to ensure the managed care infrastructure needs for the DHS delivery system are met. Escalates key issues and work to resolve to maintain contract compliance and responsiveness to internal and external customers
Works with Deputy Director, Managed Care Services on initiatives designed to foster greater integration among DHS providers and facilities, and Community Partners health centers
Works with other Managed Care Services leadership to ensure overall compliance with State and managed care payer contracts, State Department of Managed Health Care and all relevant managed care rules and regulations
Works with the Deputy Director, Managed Care Services and Managed Care Services leadership to ensure Managed Care Services Division provides excellent customer service to internal DHS customers and external constituents
Maintains continuing relationships with County administrative officials, health plan partners, contracted medical groups, outside groups, agencies, and organizations
Chairs any Utilization Management and Quality Oversight, and Credentialing Committees
Reviews clinical cases, clinical grievances, and appeals as needed
Writes, interprets and communicates clinical policies, procedures and priorities internally and to various agencies in the community
Assists with the development and implementation of programs that promote professional growth, executive and physician leadership development, and job satisfaction of staff
Experience in managed care functions such as: utilization management, grievances/appeals, credentialing, case management, or network management
Experience in public hospital systems
Experience with public insurance programs, particularly Medi-Cal

Regional Director Managed Care Resume Examples & Samples

Assesses and analyzes managed care reimbursement trends and payer policies to develop a comprehensive contracting strategy for their applicable US Oncology Network practices and strategic provider partners. Develops practice/market strategic plans (short/long term goals) to improve current programs, enhance practice value proposition and engagement, promote new payment models and increase patient volume and practice revenues. Works closely with practice executive directors, physicians and local managed care contacts to implement effective, strategic and competitive arrangements. Ensures strategies are meeting changing market, payer, pharmaceutical and/or regulatory conditions, and seeks input and support for managed care direction. Plans, develops, implements and monitors product pricing strategy and policy. Represents the company and practices with payers and ensures a coordinated contracting strategy with peers. Advises management, physicians and other staff concerning the managed care environment at the state level
Sets benchmarks to ensure that products and services are developed, packaged and negotiated in accordance with budgeted objectives to obtain maximum profitability and volume in relation to pre-set standards and specific trends within the industry. Demonstrates an ability to be creative and implement strategies that continue to move the practice toward new reimbursement models (e.g.: pay for performance, value-based contracting, episodic pricing/case rates) as well as new revenue opportunities with direct to employer initiatives, VAs, health systems/provider organizations and other “non-traditional” payer entities
Develops all contract performance criteria and establishes contracting goals for each practice and state/region at-large. Directs contract administration efforts and collaborates with practice staff and the analytics team to ensure contracts are administered effectively and operating according to expectations. Works closely with the practice and the analytics team to evaluate contracting results quarterly and provides timely updates and contract summaries. Directs development, implementation and maintenance of workable managed care policies, procedures and objectives and ensures their adequate execution and compliance by consulting with, educating and training practice management and staff as needed. Troubleshoots with practice and payer growing trends related to contract administration, claim related issues, medical policy changes and other items impacting expected reimbursement. Maintains organized payer pipeline and contract tracking reports to show successes or highlight contract challenges. Engages internal resources to address (overcome) defined contract hurdles or obstacles
Builds strong connections and collaborations with internal departments, especially applicable Regional Senior Vice Presidents, practice Executive Directors and Finance Regional Directors, as well as clinical, analytical and other practice support teams to ensure a global practice/market strategic understanding and unified approach. For some practices, provides management oversight or dotted line management responsibility with local managed care resources. Promotes the development of practice managed care committees, and leads/participates in managed care strategic discussions as well as practice leadership meetings (when appropriate)
In conjunction with Manager, creates professional development plan. Participates in professional growth opportunities, training programs and other learning sessions. Supports and adheres to the McKesson Code of Conduct, compliance requirements and ICARE. Where applicable, works with practice to ensure compliance with McKesson policies/procedures
This will be a remote based position when not traveling. The applicant will need to currently live in Florida
10+ years healthcare management experience in a managed care/health provider environment; including significant experience in managed care contracting, strategic planning, pricing and healthcare costing analysis
Expertise in managed care contracting strategies including value-based reimbursement, preferred provider strategies, and positioning centers of excellence with payers
Knowledge of the Oncology marketplace, highly preferred

Director, Managed Care-st Mary Med Center Resume Examples & Samples

Negotiate contracts with existing payors (health plans and physician organizations) based on prior contract performance, future potential and current strategic and financial goals
Analyze contractual language for functional, financial, and ethical appropriateness. Determine compliance with established legal requirements and negotiate contract language for signature in a manner consistent with the authority as delegated to this position by DIGNITY HEALTH legal counsel
Coordinate implementation of HMO, PPO, and other managed care contracts with Patient Financial Services, Admitting, Case Management, etc. Develop and maintain systems and procedures to disseminate pertinent contract information in a timely manner to appropriate regional and hospital personnel
Represent DIGNITY HEALTH in meetings with other organizations, associations, providers and payers regarding all aspects of managed care
Ensure the maintenance of comprehensive current correspondence and contract files relating to managed care agreements
Serve in a lead role within DIGNITY HEALTH regarding managed care activities, including serving on various DIGNITY HEALTH committees, task forces and negotiating teams
Ensure that all contracts and departmental actions follow the HIPPA regulations/guidelines
Prepare agendas, attachments, analysis, recommendations and minutes for Managed Care meetings as needed
Deals with Ambiguity
Business Knowledge
Financial Expertise
Manages Conflict
Timely Decision Maker
Manages Innovation
Listens
Negotiator
Organizational Ability
Organizes Self
Political Savvy
Sets Priorities
Sizes Up People
Stands Alone
Decisive, effective management and leadership skills
High degree of effective oral and written communications skills
High degree of effective advanced analytical and problem-solving skills and judgment with specific application to hospital, medical and financial data

Director Managed Care Resume Examples & Samples

Quickly develops and strengthens relationships with established Managed Care accounts
Initiates relationships with large national customers where no relationship exists
Can effectively manage relationships at the customer C-suite level, as well as at the operational level
Establish actionable, practical, and achievable goals for team members that translate into revenue growth in Managed Care
Establishes efficient process and tracking system/metrics to ensure progress towards goals are achieved
Works closely with other North America and Respiratory Care commercial leaders to ensure Managed Care strategy and individual business strategies are aligned
Effectively communicates Managed Care positioning both internally and externally to support business development, contract implementation and growth strategies
Leads on-going negotiations and subsequent implementation and maintenance of contracts for the North American and Respiratory Care divisions
Oversees Managed Care team’s book of business, to include regular reporting on contract performance, new revenue generation and revenue growth, to meet or exceed established targets
Provides day to day leadership of Managed Care personnel with a focus on professional development. Ensures direct staff is equipped with training and tools/information needed to be successful in their jobs
Maintains current working knowledge of Federal Government Acquisition and state acquisition rules

Director Managed Care Resume Examples & Samples

3-7 years, experience in managed care, preferably with prior experience in contract analysis and negotiations. Business office experience preferred
Financial analysis and negotiation skills
Moderate to Advanced Excel Skills
Knowledge of Managed Care environment

Director, Managed Care Contracting Resume Examples & Samples

Oversees and participates in the development, negotiation, implementation, monitoring and management of all assigned managed care agreements
Implements new managed care programs in conjunction with faculty, staff and hospital/practice administration. Keeps staff apprised of developments in the managed care marketplace
Directs and participates in financial analysis of revenue projections based on contractual rates with payers, adverse trends, terms and appropriate recommendations or conclusions
Develop and audit payer fee schedules based on negotiated reimbursement rates by contract and/or product line
Maintain and distribute participation information by payer by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated
Assembles information and prepares materials for presentation to committees, administrators and managed care networks
Liaison with physician practices, hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
Catalog and organize contracts along with helping maintain contracts data base and maintaining Managed Care data base
Coordinate with Revenue Cycle Groups to assure contract compliance and troubleshoot reimbursement issues
Develop strategies to link payment to performance and quality of the practices
Coordinate Physician contracting with hospital and ancillary agreements

Executive Director, Managed Care Resume Examples & Samples

5+ years of experience as a Managed Care Director in an organization comparable to HCH, Inc. or a large physician group practice
5+ years of leadership in contract negotiating experience or network development in the health insurance field
Must possess the ability to communicate and negotiate effectively with physicians and managed care organizations

Director Managed Care Resume Examples & Samples

Develop and manage a portfolio of payer contracts that optimize organization revenue, margin and growth in alignment with CHI’s mission and strategic objectives
Establish and maintain positive, appropriate relationships with market payers. Utilize communication and organizational skills to work collaboratively and credibly with payers to achieve common objectives
Work collaboratively with internal stakeholders to define and achieve common payer strategy and reimbursement objectives
Develop and execute communication plans to internal and external stakeholders related to payer relationships, negotiations, organizational contractual obligations, and developments in the managed care marketplace
Coordinate financial analysis of payer contract performance and modeling projections based on alternate contract agreements with payers, adverse trends, etc., and make appropriate recommendations or conclusions
Analyze and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements. Provide feedback to Divisional Vice President regarding financial and/or operational issues with payers
Responsible to ensure contract language in compliance with CHI Managed Care Standards & Guidelines
Coordinate with CDM around strategic pricing & coding for contract optimization
Minimum 7 years in healthcare or managed care industry. Previous experience in the provider industry is highly preferable
Proven and extensive contracting technical skills; negotiation skills, contract preparation and implementation, financial analysis and rate proposal development, and in depth knowledge of various reimbursement methodologies
Highly developed communication and organizational skills

Director Managed Care Resume Examples & Samples

Development and implementation of a Strategic Plan for Managed Care
Contract negotiations for all Managed Care Plans for Pharmacy and Optical
Assuring consistent communications with all Managed Care companies
Development of tracking reports for Managed Care contracts
Communications with Pharmacy Operations, IT and other departments for implementation of signed contracts
Assurance of consistent process for all Contract negotiations including checklist for each Contract
Development of short term, mid-term and long-term plans to attain the necessary improvements in processes and in pharmacy margins
Implementation of controls to assure that the exceptions reports are worked, tracked and reported
Collaboration with leaders to assure alignment with Shopko Mission and Vision
Relationship with Vendor for PBM reimbursement verification, optimizing and maximizing the available Vendor capabilities and tools
Representing Shopko at various Industry Pharmacy meetings (AMCP, NACDS, NCPDP)
Supervision, training and coaching of the assigned personnel
Recruitment and development of personnel
Bachelor Degree and 4 years PBM contracting experience or Master degree and 3 years PBM contracting experience
Prior work experience in Retail Pharmacy Chain or Health Plan and/or PBM
Extensive knowledge of PBMs and Managed Care Contracting
Leadership skills to oversee staff, implement initiatives and work across the organization to resolve issues
Excellent verbal and written communication skills to interact with all levels of personnel
Excellent analytical skills and proficiency in Microsoft Office

Regional Director, Managed Care Contracting Resume Examples & Samples

Creating and maintaining relationships between operations, clients, and payers related to contract performance
Maintaining client satisfaction through internal and external communication
Assisting in the development of departmental goals, executing projects to achieve these goals, and working closely with others within the department to continuously monitor department performance
Demonstrated proficiency with financial reports and modeling
Ability to work in a matrix environment where multiple and competing customer demands are likely
Self-directed with a strong bias for action
Demonstrated leadership and/or people management skills
9 years relevant experience including supervision, managed care contracting, financial analysis, payment methodologies, contract language and negotiations
Equivalent experience considered
Bachelor’s degree required

Director, Managed Care Resume Examples & Samples

Analyzes financial component of contracts using Managed Care software system
Networks with payers, providers, brokers, and others throughout the region in order to build and maintain market knowledge and market direction
Works collaboratively with the Revenue Cycle departments to ensure that contracts can be administered from a hospital billing perspective
Works collaboratively with Patient Care Coordination (PCC) to ensure that contracts can be administered from a Utilization Management perspective
Improve overall Managed Care integration into the Piedmont organization through effective communication and implementing strategic initiatives
Contacts Managed Care organizations to resolve discrepancies between contracts and payments
Meets with the PCC Utilization Review staff to identify denials problems and ongoing issues and works to resolve them
Coordinates, facilitates, or assists scheduling operational meetings between the hospital and Managed Care organization to discuss/resolve contractual and operational issues in order to enhance managed care contract performance
Gives consideration to the PR (Public Relations) implications when managing contracting and communication of the department
Monitors and updates Vice President on political, legal and regulatory trends with respect to managed care and vertical integration
Assist the Piedmont acquisition and/or service growth (i.e. facilities, physicians, services, etc.) related organizational activities in order to successful transition/implement all managed care needs

Director, Managed Care Access Resume Examples & Samples

Lead the team that will develop competitive contracting and channel strategies across the Biopharm portfolio
Lead the team that will develop comprehensive account level market models, informing both strategy development/assessment and in support of internal Sandoz groups accountable for forecasting, e.g. Target, LO, accruals, Strategic Plan
Lead buy and bill reimbursement strategy, inclusive of comprehensive ASP forecasting
Lead assessment of pharmacy benefit contracting implications on pipeline and in-line brands
Lead modeling on impact of changes to CMS reimbursement guidelines, e.g. shared J-code, implications of interchangeability etc
Collaborate with Sandoz Biopharm Managed Markets to align on appropriate product contracting strategies inclusive of financial implications
This individual requires a demonstrated ability to manage and pivot between products, customers and stakeholder requirements quickly, effectively and successfully
Oversee Biopharm stakeholder management and platform gross-to-net modeling efforts, development of broad reaching, multichannel contracting models
Develop and/or coordinate appropriate gross-to-net and contracting programs, tools, and communication materials
Minimum of 10 or more years of pharmaceutical industry experience
Minimum 5 years’ experience in contracting and/or Inline analytics/forecasting roles and/or strategic market access (Oncology/ Hematology and/or Specialty Medicine strongly desired)
Deep analytics experience, as well as knowledge and subject matter expertise across multiple channels to include Payer (Health Plans and PBMs), Specialty Pharmacy, Specialty Distributors, Wholesalers, IDNs, Clinics, etc
Experience on pre-launch planning and launch execution
Contracting and distribution strategy development experience strongly desired
Understanding of benefit design, specialty pharmacy & distribution and funding economics associated with Medicare, Commercial and Medicaid Reimbursement for both IV and Oral Pharmaceuticals
Understanding of current market access landscape and evolving macro-trends including scientific innovation, transformation of healthcare delivery, heightened focus on value and technology enabled engagement and information
Excellent strategic ability, people management and ability to develop and lead cross functional teams
Executive presence, strong collaboration and ability to simply communicate complex concepts

Director Managed Care Analytics Resume Examples & Samples

Minimum of ten years’ experience in a hospital or health care insurance environment, negotiating progressively larger participation agreements with or on behalf of hospitals
Experience working with hospital and medical group operations staff on the effective implementation and administration of agreements with managed care payers
Ability to analyze complex issues and develop, communicate and effectively deploy solutions
Highly motivated individual must be a self-starter with the initiative to identify major issues and, working closely with the stakeholders at all levels, develop and implement improvements throughout the system
Strong presentation and interpersonal skills required as the role involves working in a highly matrixed environment

Director, Managed Care Resume Examples & Samples

Designs models and performs ad hoc analysis for the purpose of understanding the historical and future performance of existing contracts
Accuracy and attention to detail are required
Ability to present information to small and, at times, large audiences
Must be able to maintain confidentiality of information
Creative, flexible, self-motivated professional must possess sound judgment ability to plan and initiate new activities consistent with achieving service excellence

Regional Director Managed Care Contracting Resume Examples & Samples

Managing existing contracts to allowable rates are achieved
Creating and maintaining strong inter-company relationships that facilitate the monitoring of payer issues such as provider participation, contract loading, and payment issues
Preparing reports and presentations to monitor portfolio performance, yield, payer enrollment, payer mix, etc
Preparing internal training or educational tools as they related to health plan contracting and/or payment policies
Conduct onsite visits with payers, clients and centers that require market specific strategies
Assume responsibility for communication and execution of corporate initiatives
Provides input to the appropriate individuals to contribute to the development of corporate initiatives
Excellent communication skills (written and verbal) to enable the presentation of data in a convincing fashion
Excellent customer relationship / management skills

Director Managed Care Va Resume Examples & Samples

Seek Diversification and Payer Competition
Seek Opportunities to Increase BSHSI Market Share
An undergraduate degree from an accredited college or university in finance, business administration or accounting required; MBA or MHA degree highly preferred
Minimum of ten years’ experience in a hospital/medical group or health care insurance environment, negotiating progressively larger participation agreements for insurance companies or on behalf of providers
Experience of managing complex population health management programs from either provider or payer perspective
Experience working with hospital/medical group operations and revenue cycle staff on the effective implementation and administration of agreements with managed care payers
Background in management administration and supervision with a minimum of ten years of progressive management experience required
Strong project management, organizational and analytical skills
Highly motivated and must be a self-starter with the initiative to identify major issues
Strong presentation and interpersonal skills required

Director, Managed Care Finance Resume Examples & Samples

5-10 years of financial/ analytical / accounting experience in physician operations and contracting environment
Strong Database skills – to manage multi-million line claims database
Modeling expertise
Intuitive sense of contracts and commoditized versus non-commoditized hospital service lines
CDM analysis and pricing expertise
A team player with strong multi-tasking skills
Excellent interpersonal and communication skills with all levels of staff, including hospital, regional offices and headquarters personnel as well as external constituents

Senior Director Managed Care Analytics Resume Examples & Samples

Lead and develop a team – develop and grow teammates, ensuring resources are optimally allocated to support business needs
Be accountable for managed care analytics – conceive and direct complex analytical work to inform decision-making, develop and implement quality assurance processes and protocols
Build and nurture strong relationships with internal and external strategic partners, including health plan and physician leadership
Develop communication process for translating analytical findings into actionable items
Facilitate and standardize request process for analytics, methodologies and models
Continuously improve managed care analytics – develop non-standard approach to new payment innovation models
Participate in payer partnership meetings to support analytic discussions
Help define and support strategic planning activities
Travel 10-20% of time
Experience in successfully leading and managing teammates of varying experience levels and location; cultivates and retains top talent/highly valued contributors
Proven ability to work in partnership with a wide array of stakeholders, and an ability to navigate the complexities of a large, complex environment
Collaborative, adaptable, pragmatic and effective problem solver
Advanced analytical and problem-solving skills with specific application to payer and/or provider data; experience working with large data sets
Strong team-player capable of building and maintaining relationships
Exceptional oral and written communications skills; able to craft and deliver clear and compelling recommendations
Strong mission and values commitment; natural cultural fit

Director, Managed Care, Physician Services Resume Examples & Samples

Leads a large department of multiple Third Party Follow Up teams that includes a staff of non-exempt and exempt positions at multiple locations
Manages outstanding accounts receivable and monitors key performance indicators including but not limited to days in AR, aging, collection rates and denial resolution to ensure client service level agreements and organization performance metrics are consistently met
Establishes goals, expectations and clear measurements to achieve optimal business results
Authors written policies and procedures as changes and/or new procedures are implemented
Produces Visio diagrams to visually demonstrate department workflows that support the written policies and procedures
Analyzes data to trend and benchmark metrics for process and performance improvement
Formulates strategic, actionable plans to achieve department objectives
Introduces methodologies and process redesign to maintain quality service
Keeps abreast of all federal, state and local regulations related to billing procedures, ensuring appropriate HIPAA and compliance guidelines are met
Recruits and develops a highly skilled, diverse work force through interviewing, training, monitoring, auditing, disciplining, coaching and completing performance evaluations
Conducts consistent internal team meetings to discuss accounts receivable performance and strategy
Participates in external meetings with clients and other key business stakeholders including sales, site assessments and vendor demonstrations as needed
Acts as leadership spokesperson in the absence of the department’s Executive Management as needed
Prepares power point presentations in preparation for various meetings both internally and externally
Maintains strong relationships with client base, providing prompt attention to their issues and/or needs
Presents feedback related to accounts receivable management and process workflows, demonstrating best practice approaches
Monitors insurance carrier updates by attending conferences, reviewing carrier announcements and list serves. Communicates changes with appropriate parties and initiates updates related to policies/procedures, systems and company education
Minimum of 10 years healthcare experience with fluent knowledge of revenue cycle
Minimum of 7 years in a leadership role including staff management, mentorship and development
Experience working in an organization of size and complexity comparable to Conifer Health Solutions
Advanced knowledge with Microsoft Office applications (Outlook, Excel, Word, Power Point, Visio)
Ability to work effectively under tight deadlines, high volumes and multiple interruptions
Strong aptitude with trend analysis and independent decision making
Excellent communication and interpersonal skills with ability to influence others from diverse backgrounds and orientations
Previous experience with practice management systems preferred; NextGen, EPIC or GE Centricity (IDX) experience a plus
Proven track record of achieving revenue targets and workflow enhancements

Director, Managed Care Resume Examples & Samples

Renegotiation of hospital and/or physician managed care agreements in accordance with the Contracting Plan developed each fiscal year
Interface with payors on contract compliance issues—this position will work closely with the business offices, case management and the CFOs to resolve disputes with the payors. Ensure that A/R days and denials (both admin and clinical) are minimized
Annual managed care market planning process on a macro and micro basis
On-going monitoring of financial performance of the managed care agreements
Assists in the negotiation and renegotiation of managed care and/or other third party payor contracts to achieve operation objectives with results that are in accord with overall market needs and budgeted targets
Carries out appropriate managed care related education and training, including the roll out and implementation of new payor contracts; and assures that new contracts are implemented in a timely and accurate manner
Participates in weekly, regional revenue cycle teleconference to address existing reimbursement related issues, including but not limited to claim denials, underpayments, and bad debt
Support of hospital and corporate strategies
Minimum seven (7) to ten (10) years’ experience
Experience with payor and/or provider
Ability to manage multiple markets/hospitals/negotiations
High degree of understanding of hospital financing/reimbursement
Communication skills, both oral and written
Ability to build and maintain relationships
Excel skills

Senior Director, Managed Care Contracting Resume Examples & Samples

Oversees and participates in the development, negotiation, implementation, monitoring and management of all managed care agreements; these agreements include more traditional fixed rate fee schedules as well as value based care agreements across all provider care settings
Implements new managed care programs in conjunction with staff and hospital administration. Keeps staff apprised of developments in the managed care marketplace
Analyze and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements
Facilitates promotion of departmental programs to provider networks
Oversee the audit of payer fee schedules based on negotiated reimbursement rates by contract and/or product line
Responsible for reviewing managed care legal contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies
Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance and value based reimbursement initiatives
Liaison with hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
Work and manage Data Analyst to establish negotiating position and work with Revenue Cycle department to assure contract compliance
Develop strategies to link payment to performance and quality

Director Managed Care Contracting Resume Examples & Samples

Manage assigned portfolio of CKHS payer contracts and relationships for all network hospitals, physicians and ancillary providers. Lead responsibility of negotiating contracts for physicians and ancillary providers, and assigned hospital managed care payers and assists in large scale ($> $15M) contracts under the direction of the Senior Director Managed Care, including rates, payment methodologies, contract language, value based and shared /full risk payment programs, following all internal controls for contract review, approval and signature and in alignment with CKHS vision, goals and objectives
Assist in the tracking of pay for performance and risk contracts with a focus on improved performance to budget, development and implementation of new reporting and tracking tools and collaboration with payers and sister organizations of CKHS. Supports managed care oversight partial and full risk contracts
Primary lead for implementation and ongoing management of completed contracts, including identification and tracking of critical contract and renewal dates, proper scanning, recording and filing of contract documents, dissemination and communication of information to internal constituents and education on new /revised terms. Monitor contract performance regarding financial performance, payment integrity, value based payment programs, compliance with contract terms and key performance indicators. Monitoring payer activity with respect to network development, product strategies, payment policies and other relevant market intelligence
Prepare and provide training, materials and tools for use by CKHS providers and their staff regarding key managed care contract provisions, market trends and opportunities for improvement in support of facility goals and objectives, consistent with the mission and values of CKHS. Proactively communicate and educate CKHS operational areas regarding contract changes, policy updates, etc., to ensure CKHS staff have information needed to successfully implement and operationalize agreements
Perform others duties as assigned/required by supervisor
Master's degree in health care administration or related field required with a minimum of 5 years of managed care contracting for multi-hospital system and or payer and reimbursement analysis in either a provider or payer setting required. Excellent written and verbal communication skills required
Extensive knowledge, experience and expertise in managed care contracting negotiations, language, modeling analytics, reimbursement methodologies on behalf of hospitals, physicians and ancillary providers, managed care regulations and quality/shared savings program metrics and methodologies
Excellent skills in Microsoft Office Excel (including advanced spreadsheet and formula manipulation), as well as in Word and PowerPoint. Access skills preferred but not required

Director Managed Care Cost Resume Examples & Samples

Provide revenue calculations and journal entries for Delaware County Memorial Hospital on a monthly basis
Set up and run all calculations on the Rapid Reserve module through MedAssets Contract Manager on a monthly basis on the 1st business day of each month for both CCMC and DCMH
Prepare all journal entries related to adjustments to revenue based on rapid reserve calculations
Insure integrity of cost data on a quarterly basis
Work with Cost Analyst to insure that the process is on schedule with monthly downloads and uploads
Review allocations of expense to appropriate departments as necessary
Review and validate reconciliations on a quarterly basis to the General Ledger for expense and Financial statements for revenue
Review and validate segment reporting for the different sites on a quarterly basis
Assist Corporate Managed care with analysis on payer contracts and negotiations
Provide detail reports of payer activity in order to compare proposed rates to the current rates
Review and approve all CDM maintenance. Provide mapping of codes to the IT department for grouping on various reports and metrics

Senior Director Managed Care Resume Examples & Samples

Manage assigned portfolio of CKHS payer contracts and relationships for all network hospitals, physicians and ancillary providers. Develop payer strategies to ensure an optimal contracting and operational outcome for CKHS providers, advocating on behalf of the CKHS providers as issues, opportunities or disputes arise. Responsible for negotiating contracts with managed care payers on behalf of CKHS providers, including rates, payment methodologies, contract language, value based and shared /full risk payment programs, following all internal controls for contract review, approval and signature and in alignment with CKHS vision, goals and objectives
Manage implementation and ongoing management of completed contracts, including identification and tracking of critical contract and renewal dates, proper scanning, recording and filing of contract documents, dissemination and communication of information to internal constituents and education on new /revised terms. Monitor contract performance regarding financial performance, payment integrity, value based payment programs, compliance with contract terms and key performance indicators. Monitoring payer activity with respect to network development, product strategies, payment policies and other relevant market intelligence
Liaison to assigned payers and operational areas within CKHS, with a focus on promoting proactive, professional and collaborative relationships, problem resolution and avoidance future of issues whenever possible
Promote enhanced use of MedAssets and other available contract management tools to support contract negotiations, revenue recovery and contract performance, providing support to decision support, finance and budget on managed care issues
Ensure CKHS providers and payers comply with all contract provisions, via tracking of performance through a variety of means, including audit of current performance via claims review, reports, etc
Work collaboratively with CKHS management, operating unit departments and support areas such as patient access, central billing offices and medical management areas to improve functions across departments and with payers
Master's degree in a related field with a minimum of 5 years of managed care contracting for multihospital system and reimbursement analysis in either a provider or payer setting required;. Excellent written and verbal communication skills required
Extensive knowledge, experience and expertise in managed care contracting negotiations, language, modeling analytics, reimbursement methodologies for hospitals, physicians and ancillary providers, shared shavings and risk contracting, managed care regulations and quality/shared savings program metrics and methodologies
Ability to handle multiple projects and perform independently under tight deadlines with a focus on effective implementation, clear and consistent communication and follow-up

Director / Managed Care Consultant Resume Examples & Samples

Identifies and secures sales opportunities with new, existing or historical clients, and strives to effectively improve and expand the reputation, image and footprint of our company
Coordinates and facilitates development of client proposals and other business development activities, including development of project scope, determination of resource budget and fees, and participation in the development of the sales strategy
Evaluate client agreements with managed care payers and propose revisions to terms and conditions intended to improve net revenues and diminish or mitigate payment risk. Evaluate payer agreements for rate sufficiency and proposed alternate rates or rate models intended to improve net revenue. Negotiate on client’s behalf directly with payers
Directs engagement teams to assure that client expectations and objectives are met, and that Quorum’s obligations as specified in the engagement agreement are fulfilled timely, cost-effectively, and otherwise as expected
Interacts and communicates with client Executives regularly on a variety of topics. Plans and leads meetings and discussions with client personnel, and internally. +Effectively and professionally interacts with others, internally and externally. Keeps client aware of engagement progress and milestones. Keeps internal personnel aware of engagement progress, barriers and needs
Obtains and maintains a working familiarity with each active client engagement, and specifically the objectives, obligations and timelines as specified within each client engagement agreement. Assures that departmental personnel have the same familiarity with those projects with which she/he is involved
Administratively responsible for the practice, including: supervision, direction, coaching and mentoring of departmental personnel; maintenance of those various information systems used to monitor and manage the department (e.g. WorkDay, Dynamics, Retain, etc.); participating in various human resource activities; and adherence to and enforcement of applicable policies, practices and expectations of our company
Responsible for the financial performance of the practice, which shall require, among other things, assertive monitoring and management of resource consumption, and maintenance of clear and common understanding of project scope and objectives with the client
Maintains currency of knowledge of healthcare reimbursement, policy and other trends pertinent to the role. Maintains currency of professional skills. Maintains active involvement in industry and professional associations
Independently performs and directs advance analytics. Identifies and designs analytic tasks for projects that involve complex or multi-faceted problems while accurately performing and directing advanced analyses
Maintains contemporary knowledge and skills relative to Managed Care and payer environments
Strong analytic and negotiation skills
Effectively manage multiple projects and tasks concurrently
Achievement of established sales goals
Minimum 7 years consulting experience strongly preferred, with 3 or more years in a managerial or project management capacity, or 10 or more years relevant industry experience desired. Substantive prior employment experience in relevant provider and/or payer settings is desired
BS/BA with Advanced degree desired

Executive Director Managed Care Contracting Resume Examples & Samples

Bachelor's Degree from a four year college or university is required
A Master's Degree is highly desirable
A minimum of 5 years of managed care contracting and network development experience for a multi-hospital system, and reimbursement analysis in either a provider or Payor setting required
Extensive knowledge, experience and expertise in managed care contract negotiations, language, modeling analytics, reimbursement methodologies for hospitals, physicians and ancillary providers, shared shavings and risk contracting, managed care regulations and quality/shared savings program metrics and methodologies
Proven experience in the successful negotiation of existing and new hospital, physician and ancillary contract rates and terms with sophisticated and profitable established managed care and provider organizations
Excellent skills in Microsoft Office Excel (including advanced spreadsheet and formula manipulation), as well as in Microsoft Word and PowerPoint. Microsoft Access skills preferred but not required
Demonstrated skills in attention to detail, superior project management, implementation and analytical ability as well as the ability to coordinate and lead activities using a collaborative and team approach
Excellent written and verbal communication skills required

Director Managed Care Resume Examples & Samples

Sets direction, develops and prepares financial and risk analysis to support senior leadership
Secure support for negotiation positions with both internal and external constitutes through strong and effective persuasive skills and technical knowledge
Works closely with the Steward hospitals and physician groups to identify systemic issues (e.g., claims, underpayments, denials) and develops resolutions that can be addressed in the contract negotiations
Monitors, interprets, and reports on changes in performance, market trends, health care delivery systems, and legislative initiatives that impact managed care efforts (e.g., CMS, ACO regulations, Massachusetts Health Reform, etc.)
Provides support for the key Steward Health Care Network (SHCN) leadership meetings including: SHCN Board Meetings, the SHCN Finance Committee, and SHCN Negotiation Committee meetings
Serve as expert on fiscal and legal provisions of the contracts
Define and lead resolution process with providers and health plans to address system-level claims operations issues
Play a lead role in the development and maintenance of key legal terms
Proven excellent written and verbal communication skills
Ability to present information to small and, at times, large audiences of various skill levels
Education: Master’s degree strongly preferred
Critical and Analytical Skills: demonstrated leadership role in developing and assessing risk and FFS reimbursement models
Software/Hardware: Strong knowledge in Microsoft Office applications – Word, Excel, Access, and PowerPoint; proven ability to learn new information systems as necessary