The Manager of Payor Contracting supports the Senior Director of Payor Contracting and Contract Operations in negotiating agreements which benefit DaVita Medical Group, the healthcare professionals it represents, and the patients it serves. This position is responsible for identifying and evaluating payor opportunities, determining optimal reimbursement rates, drafting and managing contracts, serving as an organizational subject matter expert on existing capitation and fee for service agreements for the California Market, and researching and resolving payor issues. Role will have direct and indirect reports, and require strong collaboration with multiple teams (Provider Contracting, Contract Operations, Regional Operations, UM, QM, Billing, Finance, etc). This individual will represent Payor Contracting in interdepartmental initiatives, such as business development/market expansion, payor directory clean-up, AEP, quality programs, and internal/external operations managed care education.
Essential Duties and Responsibilities:
Leads contract negotiations, as assigned. This may include, but is not limited to, capitated health plan agreements and fee-for-service negotiations with HMO’s, PPO’s, ASC’s, UCC’s etc.
Circulates draft contract terms/language to Legal, Finance and Medical Management teams for review & approval.
Identifies breaches and material changes to contracts and works with the appropriate parties to remedy them.
Applies knowledge of managed care, healthcare laws, and the Knox-Keene Act in developing contracting strategies and solving problems.
Keeps abreast of industry trends, anticipates implications and opportunities, and collaborates with the management team in developing and managing work plans for Payor Contracting activities.
Reviews health plan contract language, and is familiar with payor, medical group/IPA, and hospital/ancillary contract language and reimbursement mechanisms.
Provides contract insight to the capitation management team (Health Plan Analysis), business office and claims shop to ensure accurate and efficient loading of contracts and claims payment.
Develops, implements, and manages the Division of Financial Responsibility (DOFR) documents for entire California market
Answers and/or resolves urgent inquiries from health plans or internal departments in a timely manner
Establishes good working relationships with health plan representatives, as well as internal teams (Legal, Compliance, Regional Operations, Finance, Patient Support Center, Billing Office, etc.).
Develops tools (e.g., dashboards, grids, tables, summaries) as needed to provide organizational leadership key contract data.
Leads and assists in coordination of health plan and DMHC audits. Coordinates with internal departments on responses to external audit requests to ensure continuous compliance.
Interfaces with internal cross-functional teams (e.g., Business Development, Regional Operations, Eligibility, Finance) to provide strategic and tactical guidance on post-acquisition integration from a health plan perspective with a focus on network expansion and membership retention.
Supports the streamlining of business development processes by creating internal resources through external research with health plans
Other duties as assigned.
Soft Skills Requirements:
Ability to manage a team with a wide range of skills and professional development needs.
Ability to make independent decisions.
Ability to interact with health plan partners, providers, and teammates.
Must be able to change thought patterns quickly.
High attention to detail and personal organization.
Ability to multitask.
Strong analytical background.
Strong contracting knowledge, especially PPO & leased network contracts, specialty contracts (behavioral health, vision, etc.), ASC contracts, urgent care contracts, and capitation agreements.
Experience with building and understanding financial models analyzing health plan agreements.
Strong teammate management experience.
Bachelor’s degree preferred.
5 years or more experience in managed care contracting/contract administration.
Health Plan or provider group/IPA experience preferred, but not required.
Prior experience with FFS, capitation, and risk sharing arrangements.
Prior experience with government programs (Medicare, Medi-Cal, Cal MediConnect).
Prior experience working with health plan counterparts.
Advanced MSWord capabilities: find & replace, redlining, comment insertion, track changes and document compare.
Proficient in MSExcel (including use of functions and pivot tables) and PowerPoint software.
DaVita Medical Group manages and operates medical groups and affiliated physician networks in California, Colorado, Florida, Nevada, New Mexico, Pennsylvania and Washington. A leading independent medical group in America, DaVita Medical Group has over two decades of experience providing coordinated, outcomes-based medical care in a cost-effective manner. As of June 30, 2017, DaVita Medical Group’s teammates, employed clinicians and affiliated clinicians provided care for approximately 1.7 million patients. DaVita Medical Group’s leadership development initiatives and social responsibility efforts have been recognized by Fortune, Modern Healthcare, Newsweek and WorldBlu.