Implements, monitors, and evaluates MedStar agreements with managed care payers. Participates in the negotiation of payer contracts, development of network carve-outs and global pricing arrangements, and in the assessment and communication of managed care trends. Serves as a project manager for various initiatives such as the development of managed care improvement plans, and ongoing assessment of payer satisfaction. Manages relationships with payers and assists in the coordination of managed care functions throughout MedStar.
Education/Training Bachelor's degree in Finance, Business Administration, Hospital Administration or related clinical field; MBA, MHS or other graduate degree with a health care concentration preferred.
Experience 3 years healthcare experience, including 2 years managed care payer experience; experience in healthcare reimbursement and CPT and ICD coding; knowledge of clinical delivery setting, healthcare insurance, regulatory setting, and provider contracting arrangements.
License/Certification/Registration No special certification, registration or licensure is required.
Knowledge, Skills & Abilities Working knowledge of spreadsheet and database software applications. Excellent written and oral communication skills. Strong analytical and problem solving skills. Broad knowledge of healthcare delivery; ability to navigate and educate large system with diverse priorities and expectations. Familiarity with provider networks and contractual arrangements. Understanding of contract terms and legal requirements, including those at the federal and state level. Ability to work under general to minimal supervision, Ability to work collaboratively with internal and external customers.
Primary Duties and Responsibilities
Assists in auditing of provider accounts to evaluate health plan compliance with contract payment terms.
Completes contract development under own responsibility for a number of smaller MedStar agreements and under guidance of director for larger MedStar agreements.
Completes external market analyses by compiling published financial and utilization information on managed care companies and competitor providers. Develops an overall assessment of the current healthcare market situation to assist in the selection of managed care companies targeted for relationships with MedStar, to influence internal strategic decisions regarding program development, to monitor payers' market and financial performance.
Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards, and safety standards. Complies with governmental and accreditation regulations.
Coordinates multidisciplinary forums within MedStar for managed care orientation sessions and other payers, Presentations: Responsible for disseminating communication among internal MedStar Health staff on payer policies/procedures; . Responsible for providing education of internal MedStar Health staff on managed care, provider credentialing and enrollment, and other applicable areas for which staff require education, via Managed Care Basics or other special training seminars, Managed Care Forums & IDX User Group Presentations.
Creates and maintains files of MedStar physicians participating in managed care programs at Hospitals and MedStar Ambulatory groups, and files of hospital utilization and other statistics. Serves as project manager for credentialing and enrollment activities associated with practice acquisitions, MedStar Ambulatory Service initiatives and MedStar service line consolidations.
Develops communication channels with Medical Affairs Office and Physician Billing staff to assist them in updating current listings of physicians and/or completing any managed care credentialing and reporting projects. Develops internal channels of communication with participating physicians including those employed, contracted, or private to facilitate the written and oral dissemination of information regarding contractual changes and procedures, new payer agreements, opportunities, etc.
Develops profiles and reports on the managed care payer specific utilization of MedStar facilities for use in proposing and implementing contract revisions, expansions, renegotiations, etc. Creates and maintains utilization and financial databases for MedStar entities, to the extent possible, for use in performing historical and impact analyses on specific services and contracts.
Develops strategies to increase managed care utilization of various services in conjunction with clinical administrators and medical staff (oncology, rehabilitation, ambulatory surgery, cardiac surgery, burn services, women's services, etc.). Negotiates single case agreements to protect MedStar Health with out of network payors.
Effectively represents MedStar to payers as an integrated system and communicates available services on behalf of the hospital and diversified businesses, and in return, effectively communicates market demands and payer needs to MedStar representatives.
Establishes and implements MedStar Audit requirements for Health Plans requesting HEDIS, risk adjustment or other medical record audits and acts as liaison with MedStar entities to facilitate compliance.
Facilitates successful implementation and maintenance of new and existing contracts with Patient Accounts, Admitting, Finance, and other departments. Ensures the smooth implementation of contract terms and works internally and externally to resolve contract problems as they arise.. Assists Marketing, as needed, in the development of collateral material.
Initiates and completes contract amendments to reflect MedStar growth and entity changes.
Participates in multidisciplinary quality and service improvement teams. Participates in committees and represents MedStar in community outreach efforts.
Performs other duties as assigned.
Recommends future contract changes that will prevent operational problems, enhance reimbursements, and secure volume.
Researches payor policies, coverage issues, legislation and trends that may impact payer contracts and reimbursement, prepares summaries and reference tools for Managed Care and other MedStar departments.
Serves as central point of payer contact and troubleshooter for MedStar on payer issues, coordinates resolution of claims payment issues and settlement agreements. Assesses payer satisfaction with MedStar. Works with internal operational managers, committees, etc. to implement managed care improvement plans and resolve issues.
Serves as key member of interdisciplinary team (physicians, finance, and administrators) in the development of package pricing rates for various services (i.e. cardiac surgery, heart transplant, site specific radiation therapy, cardiac rehabilitation, joint replacements, etc.) Works to ensure successful contract negotiation and implementation of such exclusive arrangements.
Supports the enrollment and termination of MedStar physicians and other provider types in managed care plans targeted for participation; escalates enrollment issues to MedStar payer liaisons for resolution. Assists with reconciliation projects to ensure the accuracy of payor files to maximize accuracy of payments.