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Dignity Health is one of the nation's largest health care systems. As of June 30, 2017, Dignity Health operated more than 400 care centers, including hospitals, urgent and occupational care, imaging and surgery centers, home health, and primary care clinics in 22 states, through its network of more than 9,000 physicians and more than 60,000 employees. Headquartered in San Francisco, CA, Dignity Health is dedicated to providing compassionate, high-quality, and affordable patient-centered care with special attention to those who are poor and underserved. In its fiscal year ended June 30, 2017, Dignity Health provided $2.6 billion in charitable care and services. More information on Dignity Health is available at www.dignityhealth.org .
Job Summary - Manager, Managed Care
This position is responsible for contracting and administration of third party payor agreements and related activities for Dignity Health. The primary functions include performing ongoing contract development, negotiation and implementation as well as various support functions for professional and ancillary service agreements on behalf of Dignity Health Medical Group, other designated physician groups, ancillary service providers, affiliates, joint ventures and other Dignity Health business arrangements.
This position is essential to Dignity Health's relationships with its payor partners, medical groups and other affiliated providers. It collaborates with Dignity Health leaders to plan and implement strategies to grow accretive market share through payor-provider partnerships, and to promote the value of Dignity Health's services by developing innovative approaches to secure optimal reimbursement terms while protecting the interests of Dignity Health. It is also responsible for contributing to strategic planning, strategy implementation, and planning, organizing, directing and conducting the negotiation and implementation of managed care agreements with current and prospective purchasers of healthcare services or providers (in support of capitated risk) on behalf of Dignity Health.
This position leads Dignity Health's relationships and contract negotiations with multi-market health plans (multi-state and/or system-wide) as well as being directly involved in projects required under Dignity Health's current strategies and innovative projects designed to increase the value of Dignity Health's services by collaborating with physicians and/or health plans in new ways.
Additionally, this position is responsible for ensuring effective coordination and collaboration between the Managed Care Department and other functional areas, such as: operations, strategy, finance, communications, legal, and revenue cycle services.
This position reports to Dignity Health's Vice President, Managed Care for the Arizona Service Area.
This position shares support of an Executive Coordinator with a Vice President and 2-3 managers/directors.
1. Positions Scope
This position is directly responsible for the leadership and performance of activities relating to managed care, including payor relationships, the analysis, maintenance, negotiation, renegotiation, and management of managed care agreements with current and prospective purchasers of healthcare services. This includes coordination with Dignity Health and hospital leadership and staff regarding the implementation of and compliance with managed care contracts. This position is a key participant in joint operating committee meetings with payers.
This position is responsible for working collaboratively within Dignity Health regarding managed care activities, including serving as a key member of the Dignity Health Managed Care Leadership Team, serving on various Dignity Health committees and task forces, and in representing Dignity Health on multi-market negotiating teams.
This position is responsible for providing support to local Dignity Health leadership, developing and enhancing relationships with internal stakeholders, working in concert with other teams to respond to changing or emerging initiatives, and taking a lead role in the implementation of payor strategies.
Internal - Work closely with the other members of the Managed Care team for the Dignity Health, including the Vice President, Managed Care, Chief Financial Officers, Hospital Presidents, lead executives of St. Joseph's Medical Group, lead executives of Arizona Care Network, Vice Presidents of Strategy, Directors of Patient Financial Services, Dignity Health Senior Vice President, Managed Care, and the Dignity Health Managed Care Leadership Team in implementing and executing managed care strategies.
Committees - Various Dignity Health committees and task forces and other area Managed Care industry forums and operating committees.
External - Manage and enhance relationships with third party payors and purchasers, medical groups, ancillary providers, governmental agencies involved in contracting and managed care, physicians, primary medical groups, out-of-network providers, and various healthcare trade associations such as AHA, MGMA and HFMA. Manage and enhance relationships with joint venture partners, such as joint venture facilities and other provider organizations.
3. Major Challenges
A major challenge of this position is to handle multiple important responsibilities concurrently, such as: building and enhancing relationships with payors, Dignity Health leaders, and leaders of Dignity Health joint ventures; strategic planning; leading and conducting negotiations of managed care contractual relationships while keeping pace with the rapidly changing health care industry and new health care delivery models.
Dependence on the commercial sector for financial sustainability continues to grow as the non-commercial segment of the organization's payor mix continues to receive reimbursement increases below cost inflation, the importance of the role of the Managed Care Department increases. These challenges are complicated by external pressure to reduce the relative cost increases of healthcare through increased discounts to the payors, together with internal pressure to improve financial performance through decreased discounts. In addition, the Arizona market has grown increasingly competitive with a greater prevalence of narrow provider networks and heavily directed value based financial risk models. This requires Dignity Health to develop and successfully implement innovative strategies to compete for market share.
4.Freedom to Act
This position has the accountability and authority to recommend strategies, goals and priorities, and recommend policies and procedures. This position has the authority to authorize expenditures within the limits specified by Dignity Health policy.
This position has the authority and accountability to implement approved managed care strategies, negotiate contractual terms with managed care entities within approved objectives, principles and parameters established by Dignity Health, Hospital Presidents and CFO's, Dignity Health legal counsel, and the Dignity Health Vice President, Managed Care. This position is responsible for reviewing and approving such terms for signature by Dignity Health leadership.
5. Additional Key Activities
Assist in other areas as directed by Dignity Health's Vice President, Managed Care.
6. Principal Accountabilities
Ensure that all actions taken and methods used to produce the results outlined below incorporate and promote the Mission and Philosophy of Dignity Health and its sponsors.
Develop and enhance relationships with internal and external stakeholders. Proactively plan, prioritize, collaborate and communicate regarding projects, issues, and negotiations to ensure relationships are maintained and Dignity Health's values are demonstrated on a day-to-day basis and when difficult business decisions need to be made.
Negotiate managed care contracts with new and existing payors (health plans and other provider organizations) based on: strategic and financial goals, prior contract performance, projected contract performance, and thresholds approved by the hospital presidents and CFOs, physician organization executives, joint venture leadership, and the Vice President, Managed Care. Ensure contracts are negotiated or re-negotiated in accordance with established timelines.
Collaborate with internal Managed Care team and coordinate activities for analysis, negotiation and implementation of contracts with payors, including the development and production of a variety of financial projections in support of contract negotiations and related projects. Use data to determine areas where rates can be potentially improved.
Collaborate with other Dignity Health leaders to plan and implement strategies to grow accretive market share, to promote the value of Dignity Health's services, and to offset operating losses incurred serving Medicare and Medicaid patients.
Analyze contractual language for operational, financial, and ethical appropriateness. Determine compliance with established legal requirements and finalize contract in a manner consistent with the authority delegated to this position by Dignity Health legal counsel.
Ensure contractual requirements, updates on policy and operational changes, and other contract-related information is communicated to the appropriate areas within the organization and affiliates or joint ventures. Act as primary liaison with managed care plans in addressing operating issues arising under the managed care contracts. Help resolve technical and operational problems. Evaluate the impact of solutions to ensure goals are met.
Represent Dignity Health in meetings with other organizations, associations, providers and payors regarding all aspects of managed care.
Organize and plan monthly conference calls with hospital presidents and CFOs, physician organization leaders, and joint venture leaders. Provide guidance on payor-related documents, correspondence, and policies; make recommendations.
In partnership with the Patient Financial Services Director, direct the development, implementation and maintenance of methodologies to ensure receipt of proper payment from contract payors, including periodic assessments of contract compliance. Assist with payor issues such as contract disputes and denials.
Coordinate with Information Technology and other Dignity Health and hospital departments regarding the operation, utilization, maintenance and selection of managed care-related information systems.
Manage contracting efforts through the entire contract life cycle: market assessment, evaluation of opportunity, contract negotiation, contract implementation, performance monitoring, and re-evaluation. Assist with development of policies and procedures related to the contracting process; make recommendations for improvement.
Responsible for ongoing monitoring, achievement, and maintenance of customer satisfaction and applicable survey scores consistent with organizational and departmental targets.
Responsible for collaborating with the Communications Department to plan and implement communications regarding contract negotiations to the internal and external audiences such as internal medical staffs, medical groups, patients, employers and brokers, and the media as applicable.
Anticipate which contracts will not be renewed through negotiations and effectively recommend and implement approved strategies which minimize disruptions in patient care and relationships with patients, physicians, employers and brokers; and optimize Dignity Health's financial performance and market share within the Arizona market, as well as across the Dignity Health System.
Work with internal departments and external parties to negotiate Letters of Agreement for non-contracted services.
Commitment to personal growth and development by participating in internal and external activities related to professional goals.
Bachelor's degree in business or related field or equivalent experience
At least five years' managed care contracting and/or operations experience and demonstrated competencies with a health plan, hospital, medical group, or ancillary services provider organization.
Additional experience in provider relations and client services is preferred.
Proficiency with Microsoft applications: Word, Excel, PowerPoint is required.
Specific Knowledge and Skills
Decisive, effective leadership and management skills.
A high degree of effective oral and written communications skills.
Capable of maintaining and building relationships while simultaneously achieving Dignity Health's short term and long term business objectives.
Comprehensive, expert knowledge of healthcare managed care principles and financial models. Thorough understanding of managed care operations (i.e. patient referrals, claims process, eligibility, contracting, compliance, etc.).
Demonstrated ability to perform managed care contract analysis, review and interpret contractual language provisions, and support managed care initiatives. Ability to negotiate managed care contracts and develop and draft contract language.
High degree analytical and problem-solving skills and judgment with specific application to professional and ancillary services.
Advanced capitation and capitation management skills, including knowledge of actuarial principles and risk evaluation methodologies necessary for designing reimbursement models, calculating and evaluating reimbursement rates, and forecasting effect on revenues and expenses.
Ability to consistently prepare and review financial analyses, rate projections, and rate proposals.
Must possess effective negotiating skills and operate effectively in situations involving high-level negotiation.
Knowledge of legal principles and regulatory requirements relating to managed care risk and fee for service contracting, including the ability to exercise independent judgement in finalizing contract language.
Comprehensive knowledge of healthcare market, provider organizations and ancillary services.
Working knowledge of finance and accounting, including patient accounting principles and operations.
Knowledge of information systems and their application to managed care and health care organizations.
Working knowledge of HPCSs, APCs, ICD-10 and other coding methodologies as they apply to managed care.
Must be able to organize, plan, and prioritize activities with specific attention to higher level strategies while ensuring that details are also effectively addressed.
Proven leadership skills; ability to work independently and collaboratively both intra-departmentally and inter-departmentally. Ability to recognize, evaluate and resolve problems.