Senior Consultant, Managed Care

Summary:

The Senior Consultant of Payer Relations, under the direction of the VP, Payer Relations, is responsible for the client relationship with a select group of client hospitals.  The client relationship responsibilities include service and support as the primary liaison between the hospital and managed care payers.  The individual will provide written assessments of proposed managed care agreements as well as contract negotiation and support.  Additional duties include but are not limited to assisting clients with payer communication and administrative issues, delivery of educational programs for clients, coordinating the development of contract models and maintaining a customer database of activity. This position will participate in client engagements in support of the project team and prepare and present client deliverables.

Duties and Responsibilities:

• Responsible for the engagement life cycle and its relationship to project activities while producing client ready deliverables.

• Leads negotiation of provider and payer ensuring alignment with organizational goals and financial targets

• Leads complex contract initiatives, including new provider network, negotiation cycles, or service expansions

• Review and analyze data for contract administration – evaluate the profitability of contract renewals/existing contracts

• Work with Payer Relations Team to establish a work plan, set priorities, organize tasks, resource needs and recommend appropriate methodologies, tools and resources to optimize project profitability.

• Develop and maintain resource materials/tools for clarification of contracts (language templates)

• Responsible for managing client expectations in line with budget and project objectives.

• Assist with updates to the Contract Tracker, Contract matrices, Client Agendas and other documents used to communicate project status and updates with the clients. 

• Ensure annual escalators from payers are requested, validated, updated in the Contract Matrix, and shared with hospital staff.

• Track contract performance post contract execution and recommend adjustments as needed (i.e, chargemaster increases, etc)

• Maintain accurate documentation of any negotiations, contract versions, and final agreements

• Prepare negotiation, assist with financial models, complete analysis and strategy options and recommendations for leadership

• Develop negotiation strategies based on trends, regulatory requirements/guidelines, and competitive markets

• Conduct detailed claims analysis to assess financial impact of proposed contract terms

• Analyze contract terms, reimbursement methodologies for all negotiations

• Implement best practices and process improvements for contract lifecycle management

• Possess a keen understanding of managed care contracting and related initiatives, as well as the underlying systems that support those initiatives.

• Identify and analyze user requirements, procedures, and problems to improve existing reimbursement and identify opportunities for improvement.

• Perform detailed analysis on multiple projects, recommend potential business solutions and ensure successful implementations.

• Monitor market research on reimbursement benchmarks, network adequacy, and industry trends. Develop, share, and incorporate organizational best practices into business applications.

• Build and maintain strong relationships with providers, health systems, payers, and other partners

• Prepare high level reports summarizing negotiation status, outcomes, financial impact and strategic recommendations

• Provide strategic guidance to clients and/or leadership on trends such as value-based care, telehealth, and alternative payment models.

• Manage day to day client relationships while managing client expectations in line with budget and project objectives

• Assist Payer Relations Team in managing quality of the work product and interact directly with mid-level client contacts and above on engagement issues.

• Ability to deliver client reports within 30 days of a client meeting.

Knowledge, Skills, and Abilities:

• Proven track record of achieving goals and objectives as it relates to managed care contracting

• Intermediate level of analytical skills and experience

• strong communication skills: ability to interact with multiple levels of clients (ie hospital/physicians/payor plans/corporate staff)

• Proficient in Microsoft applications- Word/Access/Excel

• Intermediate level Excel experience (pivot tables, V-lookup’s, etc)

• Critical thinking and problem-solving abilities.

Work Experience, Education, and Certifications:

• BS/BA preferred in a related field or relevant experience is desired.

• Understanding of Medicare/Medicaid government contracting, reimbursement, and regulations

• Healthcare experience required.   

• 3-5 Managed Care and/or Payer Relations experience required.

• Experience working in a managed care environment for a healthcare delivery system (Professional or Facility managed care experience in this environment is sufficient).

• Possess strong negotiating skills with a successful track record negotiating contracts with individuals, groups, complex systems.

Travel Requirements:

• Up to 50%