Rural Wisconsin Health Cooperative Job Northern Kentucky USA,Healthcare

Director of Insurance Contracting & Relations

The Director of Insurance Contracting & Relations is responsible for a variety of activities that enhance health plan and payer contracting of RWHC Network members, assist in contract and payment issues, and inform advocacy efforts of RWHC. This position serves as a key member of the Senior Staff Team (SST). This position is highly visible inside and outside the organization therefore requiring a high level of professionalism to develop and maintain credibility across the healthcare industry.

Specific

Responsibilities

1) Establish, improve and maintain provider and payer relationships
2) Manage activities of RWHC Network (commercial contracts and payers):
- a) Review & negotiate RWHC approved language templates for participating provider agreements submitted by members or payers.
- b) Assist members in review of individual components of contracts as requested
- c) Negotiate non-financial contract terms with receptive health plans
- d) Assist members with operational and administrative issues including but not limited to claims payment issues, denials, prior authorizations, policy changes, etc.
- e) Meet with health plan representatives as needed to advise of issues of specific importance to members and resolve contract issues
- f) Educate members on payer trends and payer specific issues
- h) Answer member inquiries about health plans
- i) Prepare agenda and facilitate periodic Network meetings (3-4 x per year) including scheduling of guest presenters from payers, CMS, Quarles, etc.
3) Manage activities of RWHC LLC (Governmental Plans including Medicare and Medicaid):
- a) Prepare agendas and facilitate annual meeting for RWHC LLC
- b) Negotiate contract terms within parameters of LLC agreement and members of opt-in opportunities
- c) Advise health plans regarding specific issues of importance to members
- d) Educate members and respond to inquiries regarding Medicare Advantage offerings and issues
4) Manage activities of Rural Contract Consulting Services, LLC ("RCC")
- a) Assist RCC clients in developing contracting strategy and executing said strategies as directed by the client
- b) Review and execute Non-Disclosure agreements as necessary
- c) Serve as primary contact in negotiation of both language and economic terms of agreements
- d) Adhere to strict confidentiality and protecting of competitively sensitive information to avoid any anti-trust issues
- e) Track billable hours of service provided to each RCC client and prepare quarterly invoices for billing of services
5) Participate in RWHC Board meetings
6) Participate in SST management and All-Staff meetings.
7) Gather and disseminate intelligence on payer dynamics, clinically integrated networks, class actions, and other related payer/managed care trends
8) Serve as a liaison with Quarles to support members with legal review and guidance. Review invoices from Quarles for legal services rendered to RWHC Network, LLC or RCC for approval to pay
9) Collaborate with WHA and participate in applicable committees or work groups
10) Participate in RWHC Maternity Service Work Group and provide input on reimbursement and other payer related aspects
11) If funded, lead HRSA or Rural Health Transformation Program grant work supporting improved insurer relationships with rural hospitals.

General Responsibilities

§ Ability to work as a team member and serve as a team leader.
§ Demonstrate creative problem-solving skills.
§ Ability to coordinate multiple projects and deadlines and balance meeting the varying needs of multiple constituents.
§ Be able to analyze many variables and recommend the most effective course of action for each organization at any given point in time. Must be able to assess possible business and legal ramifications of recommendations.
§ Be…