SYSTEM West Virginia University Health System
Director, Payer Relations & Contracting
SYSTEM West Virginia University Health System, Morgantown, West Virginia, United States, 26501
Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.This position is responsible for leadership of organizational strategy relating to managed care contracting and negotiating physician, hospital, and ancillary services contract reimbursement rates, structure, language, and terms in conjunction with goals established by the organization, the Assistant Vice President, Payer Relations & Contracting, and the Chief Strategy Officer of the West Virginia University Health System. Directs, conducts and supervises negotiations with insurance companies, HMOs, direct to employer agreements, and other payers on behalf of Health Partners Network (“HPN”), West Virginia University Health System (“WVUHS”) entities, WVU Faculty Physician practices, and other WVUHS affiliates such as the Ohio Valley Surgery Center (currently a combined total of 25 hospitals and approximately 5,000 physicians).
This position will present managed care contracting options to senior management based on: 1) the organization’s market strength, 2) market trends, 3) market rates and 4) organizational clinical integration efforts. Further, Director is responsible for leadership of the team handling execution and maintenance of payment modeling system, contract documents, communication and education of contract terms and conditions to appropriate parties throughout system, resolution of major payment disputes, evaluation of payer performance trends, and maintaining messenger model rules and regulations to assure compliance when contracting for HPN and WVUHS.
Oversight includes appropriate review, reporting, and trend analysis necessary to recommend managed care contract improvement for provider contracts and various program initiatives. This position will present well organized information to the Assistant Vice President, Payer Relations & Contracting and other senior management and various operating areas and staff. This leadership role supports the development and evaluation of new business relationships with managed care payers and providers. The role is also responsible for the contracting strategy and implementation of all newly acquired groups and hospitals beginning with the due diligence component through to the contracting with payers assuring that the managed care contracting needs of each new entity is addressed promptly.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
Baccalaureate degree and a Master’s degree or above.
EXPERIENCE:
Seven years of progressive experience in health care management involving: Payer contract strategy and negotiations for physician, hospital, outpatient surgery centers, skilled nursing facilities, and ancillary services. Payer contracting for risk contracting with HMOs and other types of payer agreements that require risk assumption by providers. Experience in working with individual physicians, group practices, IPAs/PHOs, and other groupings of physicians, hospitals, surgery centers, and ancillary service areas.
CORE DUTIES AND RESPONSIBILITIES:
The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
Assumes primary responsibility under the direction of the WVUHS Assistant Vice President, Payer Relations & Contracting for coordinating and leading managed care negotiations.
Directs, conducts, and supervises negotiations with insurance companies, HMOs, and other third-party payers.
Prior to negotiations existing reimbursement rates, current contract, performance, current market concerns, and negotiation strategy will be reviewed with the Assistant Vice President, Payer Relations & Contracting. Upon approval the strategy will be shared with the CFOs and other operating areas.
New payers or plans will be presented to the Assistant Vice President, Payer Relations & Contracting prior to investing time in negotiations.
Works with payers to obtain preliminary contract language and terms for new contracts and, for existing contracts, at least six months prior to a set termination or renewal, provides Assistant Vice President, Payer Relations & Contracting with accurate modeled data showing reimbursement impact of proposed new rates and terms or an evaluation of existing contract terms.
Develops relationships, conducts meetings with contracting entities, committee meetings, and presentations as needed to review managed care contracting status, current contract terms, and payer performance to assist management in setting contracting strategy.
Evaluates payer offered financial and nonfinancial terms.
Develops counter proposals. Summarizes offers for review with appropriate HPN and WVUHS committees and individuals.
Maintains contract files for providers. Maintains physician and hospital fee information on contracted payers. Maintains hospital contract information on payers with selected competitor and benchmark hospitals. Maintains facility roster information for HPN and WVUHS.
Establishes goals and objectives relating to managed care contracting.
Ensures proper communication is maintained to all provider staff regarding managed care issues.
Leads interdepartmental teams to operationalize contract terms and payer’s policies and procedures.
Provides organizational notices and education regarding new or updated contract terms. Notification is professional, timely, and appropriate for staff and management.
Manages and analyzes contract compliance by leading meetings with payers, including appropriate PFS and Revenue Cycle staff.
Manages the analysis and preparation of payer report cards including profitability analysis, audit activity, denials, assisting with underpayment projects when PFS has been unsuccessful in their attempts to resolve the issues.
SKILLS AND ABILITIES:
Understanding of provider/payer contract issues including – physician, hospital, ancillary, and other healthcare provider payment terms. Understanding of West Virginia, Ohio, Pennsylvania, Virginia, and Maryland law related to managed care contracting and operations, including the relative application of State and federal law on various payers and insurance products. Contract issues, including indemnification/hold harmless, balance billing, billing and payment terms, and “medical necessity” issues. Roles of IPAs/PHOs in contracting, including basic understanding of antitrust issues as they relate to risk and non-risk contracts, both from payer and provider perspectives. Knowledge of major West Virginia provider organizations and sensitivity to relative dynamics of WVUHS and HPN.
Operation and/or oversight of healthcare provider business operations including payer claims and collections, including denial review and follow-up. Precertification processes, Legal review of contract documents, Provider contract negotiations, prior history with area physicians, physician groups, and hospitals help. General knowledge of Health Care Authority responsibilities helpful. General knowledge of Health Care Financing Authority limitations on physician and hospital Medicare Risk/Choice contracts helpful.
Must have superior skills in leadership, relationship management, verbal and written communications, organization, decision making and the ability to work collaboratively with multiple disciplines internal and external to the organization. Need strong skills in managing multiple tasks concurrently. Needs or requires little direction.
Marketing: Represent the organization to outside organizations for the purpose of furthering the attainment of corporate objectives. This will require that the position market the services of the organization to outside payers including employers, insurance companies and HMOs. Marketing to other provider organizations composed of physicians and/or hospitals is also required.
Negotiations: This position must negotiate successfully with third party payers to achieve the organization’s goals. The position must negotiate non-risk agreements for physician and hospital services, risk contracts, including capitation contracts, with HMOs and other payers, and all other payer related agreements.
Financial Analysis: Evaluate physician and hospital claims experience and fee proposals. The review of actuarial data as part of risk contract negotiations is also required.
Personnel Management: This position is responsible for the supervision of the positions that directly report to it as well as direct supervision of the day-to-day activities related to payer contracting. Promotes teamwork and seeks to maximize the potential of all employees.
Legal Review: Must work with the organization’s legal counsel to develop contract documents and to review documents being considered for payer or provider relationships. Must be conversant in law as it is applied to the current medical environment and work with the organization’s counsel to advise the board of legal risk.
Additional Job Description:
Morgantown, WV
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
SYSTEM West Virginia University Health System
Cost Center:
649 SYSTEM Managed Care and Payer Relations
Address:
1085 Van Voorhis Rd Morgantown West Virginia
WVU Medicine is proud to be an Equal Opportunity employer. We value diversity among our workforce and invite applications from all qualified applicants regardless of race, ethnicity, culture, gender, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, age, mental and physical ability/disability or Veteran status.
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This position will present managed care contracting options to senior management based on: 1) the organization’s market strength, 2) market trends, 3) market rates and 4) organizational clinical integration efforts. Further, Director is responsible for leadership of the team handling execution and maintenance of payment modeling system, contract documents, communication and education of contract terms and conditions to appropriate parties throughout system, resolution of major payment disputes, evaluation of payer performance trends, and maintaining messenger model rules and regulations to assure compliance when contracting for HPN and WVUHS.
Oversight includes appropriate review, reporting, and trend analysis necessary to recommend managed care contract improvement for provider contracts and various program initiatives. This position will present well organized information to the Assistant Vice President, Payer Relations & Contracting and other senior management and various operating areas and staff. This leadership role supports the development and evaluation of new business relationships with managed care payers and providers. The role is also responsible for the contracting strategy and implementation of all newly acquired groups and hospitals beginning with the due diligence component through to the contracting with payers assuring that the managed care contracting needs of each new entity is addressed promptly.
MINIMUM QUALIFICATIONS:
EDUCATION, CERTIFICATION, AND/OR LICENSURE:
Baccalaureate degree and a Master’s degree or above.
EXPERIENCE:
Seven years of progressive experience in health care management involving: Payer contract strategy and negotiations for physician, hospital, outpatient surgery centers, skilled nursing facilities, and ancillary services. Payer contracting for risk contracting with HMOs and other types of payer agreements that require risk assumption by providers. Experience in working with individual physicians, group practices, IPAs/PHOs, and other groupings of physicians, hospitals, surgery centers, and ancillary service areas.
CORE DUTIES AND RESPONSIBILITIES:
The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.
Assumes primary responsibility under the direction of the WVUHS Assistant Vice President, Payer Relations & Contracting for coordinating and leading managed care negotiations.
Directs, conducts, and supervises negotiations with insurance companies, HMOs, and other third-party payers.
Prior to negotiations existing reimbursement rates, current contract, performance, current market concerns, and negotiation strategy will be reviewed with the Assistant Vice President, Payer Relations & Contracting. Upon approval the strategy will be shared with the CFOs and other operating areas.
New payers or plans will be presented to the Assistant Vice President, Payer Relations & Contracting prior to investing time in negotiations.
Works with payers to obtain preliminary contract language and terms for new contracts and, for existing contracts, at least six months prior to a set termination or renewal, provides Assistant Vice President, Payer Relations & Contracting with accurate modeled data showing reimbursement impact of proposed new rates and terms or an evaluation of existing contract terms.
Develops relationships, conducts meetings with contracting entities, committee meetings, and presentations as needed to review managed care contracting status, current contract terms, and payer performance to assist management in setting contracting strategy.
Evaluates payer offered financial and nonfinancial terms.
Develops counter proposals. Summarizes offers for review with appropriate HPN and WVUHS committees and individuals.
Maintains contract files for providers. Maintains physician and hospital fee information on contracted payers. Maintains hospital contract information on payers with selected competitor and benchmark hospitals. Maintains facility roster information for HPN and WVUHS.
Establishes goals and objectives relating to managed care contracting.
Ensures proper communication is maintained to all provider staff regarding managed care issues.
Leads interdepartmental teams to operationalize contract terms and payer’s policies and procedures.
Provides organizational notices and education regarding new or updated contract terms. Notification is professional, timely, and appropriate for staff and management.
Manages and analyzes contract compliance by leading meetings with payers, including appropriate PFS and Revenue Cycle staff.
Manages the analysis and preparation of payer report cards including profitability analysis, audit activity, denials, assisting with underpayment projects when PFS has been unsuccessful in their attempts to resolve the issues.
SKILLS AND ABILITIES:
Understanding of provider/payer contract issues including – physician, hospital, ancillary, and other healthcare provider payment terms. Understanding of West Virginia, Ohio, Pennsylvania, Virginia, and Maryland law related to managed care contracting and operations, including the relative application of State and federal law on various payers and insurance products. Contract issues, including indemnification/hold harmless, balance billing, billing and payment terms, and “medical necessity” issues. Roles of IPAs/PHOs in contracting, including basic understanding of antitrust issues as they relate to risk and non-risk contracts, both from payer and provider perspectives. Knowledge of major West Virginia provider organizations and sensitivity to relative dynamics of WVUHS and HPN.
Operation and/or oversight of healthcare provider business operations including payer claims and collections, including denial review and follow-up. Precertification processes, Legal review of contract documents, Provider contract negotiations, prior history with area physicians, physician groups, and hospitals help. General knowledge of Health Care Authority responsibilities helpful. General knowledge of Health Care Financing Authority limitations on physician and hospital Medicare Risk/Choice contracts helpful.
Must have superior skills in leadership, relationship management, verbal and written communications, organization, decision making and the ability to work collaboratively with multiple disciplines internal and external to the organization. Need strong skills in managing multiple tasks concurrently. Needs or requires little direction.
Marketing: Represent the organization to outside organizations for the purpose of furthering the attainment of corporate objectives. This will require that the position market the services of the organization to outside payers including employers, insurance companies and HMOs. Marketing to other provider organizations composed of physicians and/or hospitals is also required.
Negotiations: This position must negotiate successfully with third party payers to achieve the organization’s goals. The position must negotiate non-risk agreements for physician and hospital services, risk contracts, including capitation contracts, with HMOs and other payers, and all other payer related agreements.
Financial Analysis: Evaluate physician and hospital claims experience and fee proposals. The review of actuarial data as part of risk contract negotiations is also required.
Personnel Management: This position is responsible for the supervision of the positions that directly report to it as well as direct supervision of the day-to-day activities related to payer contracting. Promotes teamwork and seeks to maximize the potential of all employees.
Legal Review: Must work with the organization’s legal counsel to develop contract documents and to review documents being considered for payer or provider relationships. Must be conversant in law as it is applied to the current medical environment and work with the organization’s counsel to advise the board of legal risk.
Additional Job Description:
Morgantown, WV
Scheduled Weekly Hours:
40
Shift:
Day (United States of America)
Exempt/Non-Exempt:
United States of America (Exempt)
Company:
SYSTEM West Virginia University Health System
Cost Center:
649 SYSTEM Managed Care and Payer Relations
Address:
1085 Van Voorhis Rd Morgantown West Virginia
WVU Medicine is proud to be an Equal Opportunity employer. We value diversity among our workforce and invite applications from all qualified applicants regardless of race, ethnicity, culture, gender, sexual orientation, sexual identity, gender identity and expression, socioeconomic status, language, national origin, religious affiliation, spiritual practice, age, mental and physical ability/disability or Veteran status.
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