Description
General Summary of Position
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.
Primary Duties and Responsibilities
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.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 the 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.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's growth and entity changes.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 a 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 a key member of the 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 the accuracy of payments.Participates in meetings and on committees and represents the department and hospital in community outreach efforts. Participates in multi-disciplinary quality and service improvement teams.
Minimum Qualifications
Education
- Bachelor's degree in Finance, Business Administration, Hospital Administration or related clinical field required
- MBA, MHS or other graduate degree with a health care concentration preferred
Experience
- 3-4 years Healthcare experience required and
- 1-2 years Managed care payer experience; experience in healthcare reimbursement and CPT and ICD coding; knowledge of the clinical delivery setting, healthcare insurance, regulatory setting, and provider contracting arrangements required
Licenses and Certifications
- No special certification, registration or licensure required
Knowledge, Skills, and 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 systems 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.
Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:
- Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
- Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
- Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
- More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.
About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.
MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.
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