Overview:
Under the direction of the Provider Payment Strategy Manager, this position will support the
development, evaluation, and advancement of provider reimbursement methodologies to align
with organizational strategies and objectives, including performance and alternative payment
approaches, and advise executive-level leadership regarding the feasibility of various strategies.
This position will require the utilization of a variety of methods, models, and data sources to
evaluate potential reimbursement methodologies and rates, will provide organizational education
related to Partnership’s network provider reimbursement, act as a subject matter expert, inform the
development, maintenance, and implementation of business unit policies and procedures, and
perform other duties as assigned.
Responsibilities:
- Supports the development, evaluation, and advancement of provider reimbursement
methodologies to align with organizational strategies and objectives, including performance
and alternative payment approaches, and advises executive leadership regarding the
feasibility of various strategies and methodologies, with duties including but not limited to:
o Identifies strategies and tactics to advance provider payment methodologies, including
supporting the Contracts team in language translation and development.
o Creates, models, and implements reimbursement strategies, including alternative
payment and risk payment arrangements with hospitals, primary care and specialty
physicians, skilled nursing facilities, and ancillary providers.
o Develops materials to inform executives regarding the pros and cons of various
methodologies, associated risks, and the feasibility of implementation.
o Serves as a subject matter expert with comprehensive knowledge of provider network
and payment methodologies across all services.
o Conducts complex research and analysis of various internal and external data sources to
inform provider reimbursement decisions and strategies, including evaluations of
financial impact and implications on network adequacy.
o Supports strategic analysis in the development of tactical implementation plans to
achieve objectives identified by the Executive Leadership Team or Partnership Board.
o Ensures alignment of provider reimbursement strategies with Partnership mission,
policies and procedures, revenue, and various state initiatives.
o Monitors reimbursement and policy changes and trends in healthcare market dynamics,
both locally, statewide, and nationally, and provides recommendations related to
applicability to Partnership.
o Collaborates with provider communities and internal stakeholders to provide value-added services to members and increase operational efficiencies within the Partnership
organization.
o Assists with documentation preparation required for internal and external audits, as
directed.
o Supports provider rate negotiation efforts to ensure alignment with organizational
policy.
o Evaluates contracted rates, contract language relevant to reimbursement, and
reimbursement methodologies and conducts research and data analysis to resolve
questions related to rates, methodologies, Partnership policies and procedures, and State
directives as they pertain to reimbursement.
o Supports implementation of contracted rates and collaborative relationships with
providers, the Contracting team, and all stakeholder business units, as appropriate.
o Provides analytical and pricing expertise to support Partnership’s negotiation,
implementation, and maintenance of managed care contracts.
o Supports the drafting, evaluation, and negotiation of a wide variety of different payee
contract language as approved by Partnership leadership and in collaboration with the
Contracts team and relevant business units.
o Monitors, maintains, and ensures the accuracy of a repository of current contract rates,
exceptions, and reimbursement methodologies.
o Tracks, evaluates, and collaborates to process provider rate requests and requests for
Letters of Agreement in accordance with Finance leadership directives and Partnership
policy.
o Educates internal stakeholders regarding analysis related to provider reimbursement.
o Communicates activities and/or issues identified relating to provider payment
negotiation, issue resolution, and implementation to the Provider Payment Strategy
Manager or the Senior Director of Fiscal Policy and Strategy, as appropriate.
Utilizes a variety of methods and models to evaluate the feasibility of
reimbursement methodologies, with duties including but not limited to:
o Strategic data analysis, data mining, research, and synthesized reporting related to
provider reimbursement methodologies to inform executive decision making.
o Financial analytics in developing and evaluating various models, such as risk-bearing arrangements, bundled payments, and population health strategies that will
provide members with the best appropriate care while safeguarding the use of public
funds.
o Identifies methods and models involving multiple variables and assumptions to
identify the implications, ramifications, and predicted results of a wide variety of
new and revised strategies, approaches, provisions, parameters, and rate structures
aimed at establishing appropriate reimbursement levels.
o Utilizes financial modeling to forecast the viability of various payment
methodologies and ensure that provider reimbursements result in a value greater
than actual payments.
o Supports payment modeling and providing implementation support, including
contract language development and interpretation, in partnership with Contracting
staff.
o Utilizes business intelligence tools and financial applications to facilitate analysis of
reports.
Provides support as a subject matter expert related to the provider reimbursement
function and provides guidance on departmental operations, with duties including but
not limited to:
o Provides day-to-day subject matter expertise, responding to internal and/or
external stakeholder inquiries, and participates in and contributes to cross-functional team projects.
o Drafts and maintains administrative policies and procedures related to Provider
Payment Strategy operations.
o Ensures compliance with department policies and procedures and internal and
external regulations.
o Attends and participates in internal and external meetings related to
provider reimbursement activities.
o Assists the Senior Director with budget development, purchasing, letters of
agreement, and invoice approvals.
o Supports the development and evaluation of RFPs and relevant contract
development, in collaboration with appropriate Partnership business units.
o Monitors legislative and legal changes related to provider payment functions and
ensuring compliance with same.
o Provides updates to Finance leadership, supporting and training end users, and
developing related materials.
o Assists in regulatory and independent financial audits.
o Collaborates with staff in multiple office locations and/or telecommute settings.
Supports and informs the development and implementation of business unit policies and
procedures:
o Examines processes to identify opportunities for procedure development and
improvement.
o Identifies training, process, and procedure gaps.
o Supports the development and maintenance of the Provider Payment
Playbook.
Performs other duties as assigned
Qualifications:
Education and Experience
Bachelor's degree or above in Business Administration, Computer
Science, Healthcare Administration, or related field; minimum 4 years
of experience working with a managed care organization or health
insurer, in a provider contracting or analysis role; or an equivalent
combination of education and experience may be qualifying.
Experience with physician/facility/ancillary reimbursement
methodologies is preferred.
Special Skills, Licenses and Certifications
Requires knowledge of State and Federal regulatory bodies, DHCS,
CMS, DMHC, and NCQA, and Medi-Cal and Medicare benefits.
Medi-Cal experience with a variety of contracting models using
capitation, fee-for-service, per diem, case rates, risk arrangements and
pay for performance. Knowledge of managed care concepts,
contracting, reimbursement, data, policies, and procedures. Proficient
in Microsoft Excel, Business Intelligence software, and database
applications. Valid California driver’s license and proof of current
automobile insurance compliant with Partnership policy are required to
operate a vehicle and travel for company business.
Performance Based Competencies
Excellent oral and written communication skills. Effectively negotiate
and build consensus. Ability to be flexible, adapt to change, and
prioritize assignments. Use good judgment in making decisions within
scope of authority and handle sensitive issues with tact and diplomacy.
Apply HIPAA requirements and maintain confidentiality. Be sensitive
and supportive regarding PHC members and their medical needs
Work Environment And Physical Demands
Ability to use a computer keyboard. More than 75% of work time is
spent in front of a computer monitor. Ability to move about the
department freely to assist with operational functions as needed. When
required, ability to lift, move, or carry objects of varying size, weighing
up to 20 lbs.
All HealthPlan employees are expected to:
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Provide the highest possible level of service to clients;
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Promote teamwork and cooperative effort among employees;
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Maintain safe practices; and
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Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.
HIRING RANGE:
$106,667.05 - $138,667.16
IMPORTANT DISCLAIMER NOTICE
The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.
