Manager, Payer Relations - Managed Care

Description

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The Manager, Payer Relations reports to the Vice President of Strategic Payer Relations and Performance and oversees the full life cycle of managed care contracts. This role manages contract organization and compliance, supports negotiations, develops reporting and performance tools, coordinates payer credentialing, and facilitates communication and education across the organization. The Manager also participates in payer committees, dispute resolution, and process improvement initiatives to strengthen Oceans payer relationships and revenue cycle performance.

Essential Functions:

• Organizes, monitors, and maintains all managed care payer contracts in a transparent, centralized data base that is reportable and accessible across the enterprise.
• Works collaboratively with key internal and external stakeholders to coordinate communication of contract terms and provisions. Completes education and training to various internal parties, including hospital administrative and clinical staff, regarding new or updated contract requirements.
• Under the strategic direction of the Vice President of Strategic Payer Relations and Performance, participates in the contract negotiation process to finalize and execute new agreements and to improve contractual language and reimbursement terms in existing agreements.
• Facilities single case agreements for VP approval.
• Develops payer scorecards and/or other reporting mechanisms to monitor overall payer performance. For value-based contracts, articulates Oceans’ provider scorecard results to hospital and executive leadership. Participates in process improvement to enhance potential VB contract incentives.
• Responsible for coordinating and completing payer credentialing for new hospitals and services and recredentialing or existing locations and services.
• Coordinates and participates in monthly, quarterly and annual payer operating committee meetings to ensure timely and accurate resolution of contract related items.
• Assists in payer dispute resolution projects, settlements, etc.
• Performs other duties and projects as assigned.

Requirements

Educational / Experience Requirements:

• Bachelor's Degree in a related field (e.g. finance, patient accounting, business development) or experience equivalent.
• Demonstrated experience with managed care principles, payer contracts, reimbursement methodologies (DRG, per diem, % of LOB allowable, case rates, incentive and penalty components of value based contracts), healthcare billing requirements, and managed care processes (credentialing, loading, disputes, appeals, etc) as differentiated by line of business.
• Proven ability to build strong working relationships with payer representatives, leadership, and internal stakeholders.
• Significant experience with frequent interaction via phone, email, and in-person communication.

Qualifications / Skills:

• Advanced skills in MS Word, MS Access, MS Excel, Smartsheets. Familiarity with PowerBI tools.
• Strong interpersonal and communication skills, with the ability to effectively convey complex ideas to internal and external parties, including executive leadership, attorneys, payer leadership and operational subject matter experts.
• Demonstrated initiative in staying current with changes in the healthcare market at both state and local levels.
• Ability to work independently and self-directs priorities.

Work Environment:

Subject to many interruptions. Ability to meet deadlines and comfortable working under occasional pressure due to multiple calls, inquiries and competing priority projects. This position can be high paced and stressful; must be able to cope mentally and physically to atmosphere. Work requires spending approximately 90% or more of the time inside a building that offers protection from weather conditions but not necessarily from temperature changes.