Managed Care Manager

Grady Health System offers many career paths for experienced professionals. Whether you have many years of experience or are in the early stages on your career, you can find a rewarding career at Grady!

The Managed Care Manager is responsible for Managed Care contracting analytics and contract coordination activities across the system. The Manager conducts predictive analytics by using a contract modeling tool (PMMC) to analyze rate proposal provided by both Grady and Managed Care Payors to ensure favorable financial agreements for the Grady system. Also responsible for contract reviews with emphasis on assuring that Rate Sheets are financially sound and inclusive all of all relative financial terms and contracted payment factors (Revenue Codes, DRGs, CPT Codes, etc.). The Manager will be responsible for oversight of the Joint Operation Committee Meetings (JOCs) and escalation of issues unresolved through the JOC meetings. Monitors and updates Director on political, legal, and regulatory trends with respect to financial matters affecting Managed Care. Works with Medical Economics, Decision Support and Revenue Cycle operations to produce reports concerning managed care contract performance and operations. Plans and oversees education for Patient Financial Services (PFS) and applicable Revenue Cycle departments throughout the system to educate departments concerning contract terms, language, and compliance. Facilitates resolution of contractual and operational issues with payers to enhance managed care financial contract performance. Contributes to the implementation of managed care vision and goals. Fosters positive relationships with insurers and other stakeholders in the healthcare system. This includes planning, analyzing, negotiating, and managing Managed Care financial agreements within the Grady system.

Responsibilities

* Participate in negotiations with insurance companies, third-party payers, and managed care organizations to establish contracts and reimbursement rates.

* Monitor and review managed care agreements to ensure compliance with terms and resolve any contract disputes.

* Analyze and monitor the financial performance of managed care contracts, including payer mix, reimbursement rates, and profit margins.

* Works with Grady's Population Health Department to maintain Value-Based and Quality Incentive Agreements.

* Stays current with industry trends and best practices through continuous education and networking.

* Oversees the coordination and facilitation of the Joint Operation Committee (JOC) meetings between hospital staff and Managed Care Organizations to discuss/resolve contractual and operational issues to enhance managed care contract performance.

* Serves as the point of contact between the hospital, insurers, and external stakeholders for managed care issues.

* Provide oversight and analytical reporting related to all Managed Care software analytical tools.

* Responsible for leadership oversight of contract loading and maintenance in the EPIC patient data management system, contracting database and decision support system.

* Enhancement and maintenance of the Grady Contract Matrix.

* Works with both internal and external resources to negotiate Managed Care financial contract terms and provide recommendations to leadership.

* Develops skills and provides focus on the market conditions/changes including but not limited to consumerism, value-based healthcare, transparency, risk contracting, etc. and how these changes or trends affect Grady financially.

* Works collaboratively with the Revenue Cycle departments to ensure that contracts can be administered from a hospital billing perspective. Also Works collaboratively with Patient Care Coordination (PCC) to ensure that contracts can be administered from a Utilization Management perspective.

* Collaborate with finance, clinical, and operational teams in the development and analysis of business pro-formas to support strategic initiatives, including new payer contracts, service line expansions, or population health programs.

* Plans and oversees education for Patient Financial Services (PFS), Patient Access, Revenue Cycle, Utilization Review and other departments throughout the system to educate departments concerning contract terms, language and compliance. Coordinates contract Plan orientations with the Payors as new contracts are executed and/or existing contracts are renewed.

Education

Bachelor's Degree in Business, Finance, Health Care Administration, or related field or equivalent combination of education and experience.

Experience

With Bachelor's Degree: Ten (10) or more year's experience in Managed Cre contract analytics and/or Managed Care contracting related activities.

Without Bachelor's Degree: Fifteen (15) or more year's experience in Managed Care contract analytics and/or Managed Care contracting related activities.

Skill Set

Excellent analytical skills and business acumen in the healthcare field preferably in Managed Care.

Strong people management skills and experience. Experience in EPIC and PMMC Preferred.

Payor/Provider contract modeling experience highly preferred.

Works well in a team environment or independently.

EOE-Females/Minorities/Protected Veterans/Individuals with Disabilities.