Job Summary: Under the direction of the Chief Operations Officer the Director of Managed Care is responsible for the managed care and contracting activities of Omni Family Health (OFH), to include developing and sustaining the required infrastructure to thrive in the ever changing managed care environment and ensuring timely and efficient enrollment with payers including managed care plans, Medicare, Medicaid, commercial plans, programs, and others.
- Assist the CEO/COO to develop a corporate vision and set strategies to advance, grow and optimize the managed care sector of the business.
- Ensure that revenues from health plan/ IPA/ third party contracts are optimized; renegotiate agreements as necessary; monitor incentive reimbursement; monitor value-based incentives/quality initiatives programs.
- Build, manage, and enhance relationships with third party payers, Health Plans, medical groups, hospitals, specialty networks, IPA's, governmental agencies involved in contracting and managed care.
- Negotiate and manage agreements with hospitals, specialty networks, ancillary providers as required to support the managed care activity.
- Maintain relationships with State and Federal government agencies, health care associations regarding issues pertaining to managed care programs to maintain pertinent knowledge about the changing healthcare/managed care environment affecting the organization.
- Works with the Chief Medical Officer, IT department and health plans to develop and maintain regular on-going provider utilization reporting process.
- Monitor contract compliance with health plans and governmental agencies to ensure that the terms of contracts are being met.
- Coordinate the operational activities with various departments within the Managed Care areas and responsibilities (e.g. contracting, rate negotiations, claims management, HEDIS, etc.);
- Oversee the establishment and maintenance of internal communication and education processes that assure operations are conducted in compliance with contractual terms and the establishment and maintenance of ongoing tracking and reporting systems and methodologies, in order to measure and document departmental and contract performance.
- Act as spokesperson for the managed care program to clients, medical providers, private/public agencies and organizations.
- Collaborate in the Joint Commission/NCQA review of the provider credentialing process.
- Participate in QI meetings; provider meetings, Department meetings, as required.
- Consistently demonstrate and uphold health center principles of providing quality health and human services to the medically underserved and low-income populations in a culturally sensitive manner.
- Prepare, monitor, and analyze manage care analytics and statistics recommending strategies for revenue maximization.
- Various other work-related duties as assigned by supervisor. These duties and responsibilities may be added, deleted, or changed at any time at the discretion of management, formally or informally, either verbally or in writing.
- HIPAA compliance - Responsible for maintaining abreast of and in compliance with all HIPAA regulations and requirements. Treats all member information confidential.
- Compliance - Ensure compliance with all local, state and federal regulations.
- QA/QI - Participate in QA/QI activities and contribute towards the overall performance improvement of the organization.
- IT –May be required to learn and use the Electronic Health Record and Practice Electronic System and its components. As required by the job functions and highlighted in the Policies and Procedures. These components include Next Gen, PMS, QSI and other electronic features, as they are developed and implemented, as applicable to work environment.
- All employees will participate in Patient Centered Health Home Model at Omni Family Health.
qualifications, Education, and Experience:
BA or BS in Business Administration, Finance, Healthcare Administration, or related field from an accredited college or university required. Ten plus years of experience in a similar leadership role, or higher, may be substituted for educational requirement. Any combination of education and experience, which would provide the necessary knowledge’s and abilities, is qualifying.
- Five (5) years progressive experience in Managed Care or equivalent in a health care environment; Work requires 5 years related administrative or health center management experience to acquire competence in applying general operational practices, personnel practices, accounting and budgeting principles and coordination of health center administrative functions.
- Minimum five (5) years’ experience as a supervisor preferred.
- Strong Customer Service Skills (preferably within a service industry).
- Modern office practices and procedures (including email).
- Demonstrated ability to exercise sound judgment.
- Ability to communicate clearly and concisely.
- Ability to plan and be organized.
- Ability to work well under pressure, take initiative, provide strong leadership, and motivate direct reports.
- Knowledge of legal principles and regulatory requirements relating to managed care risk and fee for service contracting, including knowledge about contract language.
- Comprehensive knowledge of health care managed care principles
- Working knowledge of capitation and capitation management skills.
- Ability to make decisions and perform job duties with minimal to no supervision.
- Ability to perform contract analysis / negotiation of healthcare managed care contracts leading to favorable reimbursement rates;
- Possess excellent analytical and problem-solving skills.
- Ability to manage multiple projects concurrently.
- Professional appearance and demeanor.
- Demonstrated proficiency in various PC applications, including E-mail, Microsoft Excel, and Word, Internet and networking devices.
Responsible to: Chief Operations Officer
Classification: Full-time; Exempt