Under the general direction of the Executive Director of Managed Care, responsible for timely analysis, negotiation, and implementation of HMO, PPO, EPO, Ancillary service and other contracts for TCMC and its affiliates in accordance with established TCMC policy. Government contracting where appropriate. Participate in operational meetings as needed. Support TCMC’s Strategic Plan.
Major Position Responsibilities:
- Represent TCMC and its affiliates in complex negotiations for HMO, PPO, EPO, Ancillary service and other third party payer contracts. Provide analysis of contract language, rate schedules, reimbursement methodologies and concerns relative to TCMC operations, including, but not limited to Patient Accounting, Finance, ancillary and other affected Departments and TCMC affiliates as may be identified from time-to-time.
- Act as liaison with the Patient Accounting and Finance Departments and work with Managed Care Contracts Manager to ensure and coordinate input from all parties in the negotiation process.
- Develop and maintain financial analytical modeling to track and evaluate contract financial performance, prepare contract renewals, and negotiate new contracts.
- Responsible for the development of policies and procedures related to the contract management process of the Managed Care Contracting Department.
- Acts as the primary liaison for administrative matters between ancillary departments, third party payors, hospital administration and network providers. Is the primary liaison within TCMC and its affiliates to coordinate contracting arrangements, problem solving, educate and ensure the flow of information and contract implementation within TCMC.
- Participates in and coordinates ongoing development and implementation of the mission, goals and objectives, management strategies, and policies of TCMC as it applies to all third party payer care contracting.
- Maintains regular communications with payers to optimize operational goals as well as evaluate contract operational and financial performance progress. Manage external notification timeframes.
- Respond to payers, physician groups and TCMC departments as a Managed Care resource to assist their needs in a professional manner.
- Respond to payers, physician groups, and TCMC departments as a managed care resource in support and/or to represent their needs in a professional and responsive manner.
- Creates and maintains a work environment which emphasizes and supports professional development through research, cooperation, team work and education as it relates to managed care concerns.
- Performs other related duties as assigned or requested.
Safety and Infection Control Responsibilities:
Responsible to maintain a safe and clean work environment, including unit based specific safety and infection control requirements.
- Knowledge of third party payer contracts including reimbursement methods and legislative issues, required.
- Minimum 7 years hospital and ancillary contracting experience, required.
- Strong knowledge of pre-paid and fee-for-service hospital and ancillary reimbursement methodologies, required.
- Knowledge of San Diego health care payer environment, required.
- Knowledge of private and government funding of hospitals and ancillary providers, required.
- Ability to communicate effectively and persuasively through written and verbal communications, required.
- Excellent management skills for planning, organizing, facilitating, coordinating, collaborating, and the ability to communicate with others, required.
- Must be dependable, have integrity, initiative, tact, ability to work on details, ability to learn and possess a sense of values and ethical standards.
- Must also have the ability to train and develop other personnel by providing them with the knowledge and working tools designed to facilitate decision-making and performance.
- MBA or equivalent, required. Emphasis in healthcare related field, preferred
- May considered equivalent experience in lieu of degree.