Managed Care Contract Manager

MAJOR RESPONSIBILTIES

• Evaluate and negotiate contracts with managed care entities in accordance with established criteria.
• Assist in the development of contracting parameters and operational parameters for each negotiation of new and renewal contracts.
• Develop and present summary of contract provisions to the physician and hospital providers and their respective staff.
• Must have knowledge of and effectively communicate all aspects of a managed care contract, including, but not limited to, financial terms, operational responsibilities, delegation issues, utilization management, quality assurance program and credentialing process.
• Manage special project assignments as directed by the Director and Vice President of Managed Care that may be requested by the Advocate providers.
• Serve as a consultant to Advocate providers on integration of managed care processes and operations.
• Assist in the development, validation and implementation of contract performance criteria.
• Manage the business relationship with contracted payers and providers on a regular basis, including gathering internal feedback and regularly scheduled meetings with payers, to assure a mutually satisfactory relationship.
• Assist in developing pricing, contracting, and provider network development strategies.
• Involvement in managed care strategy and management of product lines as related to managed care payers.  Act as a resource for contract evaluation and support to Advocate ancillary products related to managed care payers.
• Responsible for tracking the results of previous managed care experience for incorporation into managed care rate strategy for new as well as renewal managed care contracts.
• Monitor, maintain and continually improve the relationships with managed care payers, PHO site directors, PHO board and finance committees, product lines, and medical groups.
• Responsible for coordinating the review of all aspects of the contractual relationship entered into between managed care payers and the Advocate providers.  Responsible for developing standard contractual provisions with respect to financial terms, operational procedures and language provisions coordinated with the system’s legal department.
• Assure correct loading of contracted provider network contract terms.
• Participates as a front-line resource and facilitates the development of managed care pricing strategies for both facility and physician services.
• Work with the managed care organizations to execute quality, utilization, case management, credentialing programs and satisfaction surveys.
• Facilitate implementation of HMO, PPO, POS, and other contracts with all departments, including APP finance, claims, customer services, medical management, and operations; and hospital patient accounts, admitting, registration, outpatient department and inpatient utilization management.
• Evaluates viability of a business relationship by obtaining information from the client and researching the reputation, financial integrity and market dynamics of the client utilizing information from the client, external agencies and other resources in the industry and measures against established guidelines and parameters.
• Participates in the development of strategies in conjunction with Vice President of Managed Care, Vice President of Finance, Consolidated Finance Committee (CFC), and Operating Unit Managed Care Contracting Committee (OUM3C) to protect existing as well as increase market share in a dynamic market.  Serves as staff to the Operating Unit Managed Care Contracting Committee.

MINIMUM EDUCATION AND EXPERIENCE REQUIRED

License/Registration/Certification Required:  None

Education Required:  Bachelor’s degree in finance or related field

Experience Required:  7 years marketing/operations/finance in managed care environment.

KNOWLEDGE, SKILLS AND ABILITIES REQUIRED

• Ability to support contract negotiations
• Thorough knowledge of the managed care industry
• Knowledge of various provider reimbursement methodologies
• Experience working directly with provider office staff
• Excellent written and verbal communication skills
• Ability to use spreadsheet, presentation, and word processing software effectively

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.