Director, Managed Care

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

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

The Director partners closely with finance, revenue cycle, strategy, clinical operations, Beacon networks and other key stakeholders to ensure managed care agreements support the organizations financial, clinical and strategic objectives. Acts as a liaison with Centers for Medicare and Medicaid Services (CMS) and commercial insurance companies with respect to participation in value-based incentive programs. Supports the management team by providing input into the strategic planning process.

Responsibilities also include the oversight of all managed care activities for the Community Health Alliance (CHA) and implementing guidelines for PHO (Physician Hospital Organization) physician credentialing and re-credentialing. Manages the Credentialing activities for CVO and Beacon Managed Care Provider Enrollment. Responsible for managing all functions of the Accountable Care Organization (ACOs). Liaison with Centers for Medicare and Medicaid Services (CMS) to manage the MSSP Accountable Care Organization (ACO) contracts both internally and externally.

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

• Developing short-and long-term goals and objectives consistent with the goals of CHA, Provider Enrollment/credentialing and CHA ACO; also developing an annual operating plan to encompass these functions. Also assisting and/or assuming responsibility for managed care strategic plan development.
• Managing criteria for managed care contracts for CHA with Provider Relations Manager.
• Analyzing current contracts (retrospectively) to determine profitability.
• Conducting house-wide educational programs related to CHA.
• Developing and maintaining a complete contract manual listing of all contracts, services, discounts and renewal dates for facilities and ancillary providers.
• Maintaining good working relationships with current employer clients and responding to all of their future requests and questions in a timely manner.
• Performing conflict resolution with representatives of current and new CHA managed care contracts. Also providing viable solutions which will maintain solid working relationships.
• Ensuring the timely completion of initial and re-credentialing for all CHA, BMG and BHS contract providers by coordinating with outside credentialing agencies, regulatory agencies and contracted providers.
• Oversee the credentialing process and ensuring that policies and procedures are being followed.
• Managing and marketing CVO (Certified Verification Organization) services to local providers.
• Working with the credentialing software to make sure system is being used at the highest level and all appropriate information is reported.
• Reviewing and updating applications, operational policies/procedures and credentialing standards on a yearly basis, verifying all payer updates are incorporated into operational policies in accordance with National Committee on Quality Assurance (NCQA) credentialing guidelines
• Ensuring the timely completion of initial enrollment and re-credentialing for all BMG, BHS, Beacon Health LLC and any other Beacon Health System entity employed and contracted providers.
• Working closely with BMG to ensure the information provided to the…