Director of Managed Care & Payer Strategy

  • Blanchard Valley Health System
  • Findlay, OH, USA
  • Jul 19, 2022
Full Time Administration/Operations

Job Description

PURPOSE OF THIS POSITION

This position is responsible for BVHS managed care/payor contracting, strategy development and execution; leading initiatives in payment innovation & value-based reimbursement, including "direct to employer" contracting; and overseeing contracting and implementation infrastructure, analytics and reporting for the employer-based medical home program and other BVHS population health initiatives. 

JOB DUTIES/RESPONSIBILITIES

Duty 1: Contract Negotiation and Payor Relationships. Develop and implement managed care strategy to identify contracting opportunities, address evolving payment mechanisms and reforms and identify strategic alignments and opportunities. Evaluate, negotiate and secure financially, strategically and administratively favorable managed care contracts with new and existing health plans, networks and products, consistent with BVHS managed care strategy. Foster constructive professional relationships with private and public payors and serve as the principal liaison (director level) between BVHS and payors.

Duty 2: Value-Based Contract and Alternative Payments Model Strategy and Execution. Lead Payment Innovations/Value based/Performance based contracting strategy and implementation to drive care transformation and revenue generation. Lead decision making process and implementation of alternative payment innovations and initiatives and performance-based contracts. Develop and implement BVHS alternative payment products including strategy, product design, pricing build up and analysis, legal review, operational logistics and distribution mechanisms.

Duty 3: Direct-to-Employer Contracting. Oversee growth and product development of the Northwest Ohio Health Partnership (NWOHP) PPO product, jointly sponsored with Hancock Medical Group.  Lead BVHS direct to employer contracting including NWOHP PPO and development of other arrangements (e.g. bundled case pricing, tiered network steerage) to drive volume to BVHS and meet employer needs for cost containment and quality. Maintain strong employer relations to support BVHS strategy with payers through various initiatives. Maintain broker and TPA relationships for PPO growth and new product development.

Duty 4: Population Health (Appropriate Care and Utilization). Drive population health, care improvement, cost efficiency and alignment of providers and patients with BVHS through the delivery of infrastructure and analytics for employer based Medical Home program and care navigation contracts.  Measure and report on medical home program, care navigation and BVMP performance-based contracts performance to stakeholders (employers, BVHS, BVMP and Medical Home providers). Provide actionable analytics, tools, education and operational guidance to medical home private and employed provider practices, to BVMP for performance-based payment contracts, and to HMG medical management committee for medical staff education and engagement.  Promote and market BVHS population health initiatives (medical home, care navigation, value-based benefit design, etc.) to employers and brokers. Work with Blanchard Valley Health System’s human resources department on health plan benefits design. Align BVHS population health efforts related to the Community Health Needs Assessment to support a unified organizational strategy.

Duty 5: Payor Contract Compliance and Issue Resolution. Monitor health plans' adherence to contract terms; identify and intervene to resolve contractual issues and disputes with payors in a timely manner and in coordination with BVHS entities, departments and revenue cycle. Support and collaborate with BVHS clinical, operational and transactional departments to support BVHS’s compliance with contracts. Act as resource to and as "check and balance" with revenue cycle, utilization review, prior auth and other departments on payer network, credentialing and reimbursement issues and topics. Collaborate with revenue cycle to monitor reimbursement accuracy, and, as appropriate for future business needs, maintain contract information to support implementation of underpayment or contract management software solutions.

Duty 6: Provider Enrollment and Credentialing. Maintain timely and accurate governmental and payer credentialing for BVHS entities and providers to maximize revenue and patient access.

Duty 7: Hancock Medical Group Provider Collaboration and Engagement. Maintain and expand relationship with HMG to foster alignment between BVHS and private practice physicians, support Co-Management efforts and improve population health through collaboration. Includes HMG administrative support arrangement, product development through NWOHP PPO, clinical improvement initiatives through the medical management committee and other assistance with engagement and strategy implementation as set by HMG board.

Duty 8: Managed Care Environment Trends. Monitor, communicate and address environmental trends related to payers, payment strategies and purchaser initiatives. Identify issues and support BVHS adaptation to market changes and payer policy changes.

Duty 9: Pricing Strategy Development and Execution. Work collaboratively with the pricing committee to develop strategies for strategic pricing for the organization.  Provide accurate contract data to support pricing analysis work, and develop strategy for balancing the need for competitive pricing for employers and patients with the need to maintain favorable reimbursement.  Use publically available price transparency data sources to understand competitor and health plan information and identify opportunities for BVHS to optimize its pricing strategy and contracting opportunities.  Support compliance with Price Transparency requirements including monitoring changes to the regulations as well as trends in competitor compliance with the requirements and the corresponding strategic implications.  

Duty 10: Other Managed Care Project Support. Provide input and managed care perspective for other organizational projects and operational activities as appropriate.

REQUIRED QUALIFICATIONS

  • Bachelor’s degree in healthcare administration, finance, business administration or a related healthcare field required.
  • Minimum of 5 years of experience in managed care, contract analysis and negotiations, payment innovations, and/or population health.
  • Understanding of health care financing and delivery, and ability to think strategically and offer innovative solutions to complex challenges facing the system.
  • Proven track record in successful contract negotiations
  • Excellent data analytic oversight skills.
  • Excellent presentation skills
  • Strong leadership skills including the ability to collaborate on all levels of the organization; including ability to work effectively with physicians and physician organizations.
  • A valid driver's license is required (if you do not have a valid Ohio driver’s license you must obtain one within 30 days of your residency in the state).  You must also meet BVHS's company fleet policy and insurance company requirements, and any other requirements that may be required to operate a vehicle.
  • Positive service-oriented associate engagement, interpersonal and communication skills required.

PREFERRED QUALIFICATIONS

  • Master’s degree in healthcare administration, finance, business administration or a related healthcare field required.
  • Demonstrated experience and success with population health and payment innovations.
  • Demonstrated experience with product development and project implementation.
  • Physician-hospital organization and healthcare network experience

PHYSICAL DEMANDS

This position requires a full range of body motion with intermittent walking, lifting, bending, squatting, kneeling, twisting and standing. The associate will be required to walk for up to one hour a day, sit continuously for six hours a day and stand for one hour a day. The individual must have excellent verbal communication skills to perform daily tasks. The individual must be able to operate a motor vehicle for business travel and community involvement.