The Director of Managed Care, Contracting and Payor Relations is responsible for evaluating, negotiating, and securing financially and administratively favorable managed care contracts with new and existing health plans/managed care organizations on behalf of Rutgers Heath Group (RHG) and its practice divisions. Additionally, this individual will participate in and support the development of managed care strategies and initiatives for RHG to adapt to ongoing healthcare payment reforms and evolving payment methodologies, including accountable care organizations (ACOs) and clinically integrated networks (CINs). The leader will foster professional relationships with private and public payor management representatives and serve as the principal liaison between RHG and payors. This individual will also be responsible for representing the interests of RHG in discussions with other affiliated health systems or clinical partners in discussions related to managed care.
- Reports to the CFO, Combined Medical Group
- Serves as member of RHG managed care committees at both RHG-New Jersey Medical School (NJMS) and RHG Robert Wood Johnson Medical School (RWJMS); provides support and seeks consistent guidance from committee members regarding strategic direction and priorities.
- Fosters professional relationships with private and public payor management representatives and serves as the principal liaison between RHG and payors regarding contract changes and dispute resolution.
- Works in close collaboration with respective practice division leadership and RHG leadership to ensure that the needs of each practice division are being met, while balancing the overall demands of RHG as an integrated practice.
- Represents the interests of RHG in managed care related discussions with affiliated health systems as appropirate.
- Fosters relationships with RHG department chairs and faculty, clinical administrators, and other RHG and Rutgers Biomedical and Health Sciences (RBHS) executives.
Strategy and Business Development:
- Collaborates with RHG and practice division leadership to identify contracting strategy and expansion opportunities (e.g., through the development of new payor relationships, entrance into new markets, participation in new and/or innovative insurance products), including development of managed care contracting strategy across units as appropriate and desirable.
- Supports the development of managed care strategies and initiatives for RHG to lead and adapt to ongoing healthcare payment reforms and evolving payment methodologies, including ACOs and CINs.
- Facilitates RHG involvement in defining the future payment/incentive model for the New Jersey Medicaid Access to Physician Services (NJ MAPS) program.
- Remains abreast of local, regional, and national developments pertaining to managed care and advises leadership on implications and recommended actions.
Contract Negotiations and Administration:
- Defines contract negotiation objectives in coordination with the Senior Vice Chancellor, Senior Associate Dean, CFO of Combined Medical Group, as well a practice division leadership, including opportunities to incorporate new technologies, procedures, and changes in the market.
- Manages and supports analytical staff in maintaining a detailed utilization database, including utilization and payment information by code, specialty, and payor benchmarked against Medicare and other payment rates and contractual net financial performance.
- Directs analytical resources to quantify the impact of alternative proposals before and during negotiations as well as post contract execution to ensure contract compliance.
- Leads contract negotiations with payors guided by RHG s contracting priorities and informed by analysis.
- Negotiates contract language and facilitates review from legal counsel.
- Oversees monitoring of contract anniversary dates, reporting, and notification requirements, and ensures annual rates are implemented correctly and on time.
- Working in coordination with practice divisions and other managed care staff, ensures that RHG has the capability to track and report performance under any value-based or other pay-for-performance initiatives.
- Oversees and/or coordinates the collection, validation, and reporting of NJ MAPS data for the RHG practice divisions to the state.
- Develops and maintains appropriate policies, procedures, and controls for managed care and payor contracting activity.
- Monitors health plans adherence to contract terms; identifies and resolves contractual disputes with payors in a timely, organized manner and in coordination with practice division revenue cycle and other staff.
- Directs and manages assigned staff, including training, orientation, and counseling.
- Works with the Senior Associate Dean to instill, maintain, and enhance in employees the vision, mission, and values of the University, RBHS, and RHG. Heightens employee morale via open lines of communication, fair and equitable treatment, and annual evaluations of all employees.
- Selects, trains, directs, and evaluates the performance of and, when necessary, disciplines and discharges direct report personnel. Assists subordinates with difficult employee relations problems, as necessary.
- Understands and adheres to the University s compliance standards as they appear in the RBHS Corporate Compliance Policy, Code of Conduct, and Conflict of Interest Policy.
- Performs other related duties as assigned.
- Bachelor s degree in business, healthcare administration, or related field; master s degree (MA) equivalent preferred.
- A minimum of ten years of managerial experience in managed care environment, health insurance industry, or managed care product development/negotiations, preferably in a faculty group practice setting.
- Extensive experience with contract negotiations and payor relations, as well as demonstrated knowledge of legal, regulatory, and operational aspects of managed care including contract management compliance and performance analysis.
- Experience and familiarity with physician/professional service compensation, fee schedules, and resource-based relative value scale (RBRVS) - based reimbursement.
- Experience and understanding of new and evolving value-based payment arrangements, such as capitation, shared savings, and payment bundles.
- Solid understanding of patient accounting tasks including billing, collections, and reimbursement analysis.
- A track record of success working in an environment of collaboration, transparency, mutual respect, and shared passion for excellence and innovation.
- The ability to plan, organize, prioritize, allocate resources, and manage multiple ongoing, concurrent projects.
- The ability to express oneself clearly and concisely both orally and in writing with staff, physicians, and management personnel both within the organization as well as the payor community.
Note: Position will require travel to various locations relative to RHG and the Combined Medical Group. Primary locations include Newark, New Brunswick, and West Orange.
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Equal Opportunity Employer
RWJBarnabas Health is the most comprehensive health care delivery system in New Jersey, with a service area covering five million people. The system includes eleven acute care hospitals Clara Maass Medical Center in Belleville, Community Medical Center in Toms River, Jersey City Medical Center in Jersey City, Monmouth Medical Center in Long Branch, Monmouth Medical Center Southern Campus in Lakewood, Newark Beth Israel Medical Center in Newark, RWJUH- New Brunswick, RWJUH- Somerset in Somerville, RWJUH- Hamilton, RWJUH- Rahway and Saint Barnabas Medical Center in Livingston; three acute care children s hospitals and a leading pediatric rehabilitation hospital (Children s Specialized Hospital), a freestanding 100-bed behavioral health center, trauma centers, a satellite emergency department, ambulatory care centers, geriatric centers, the state s largest behavioral health network, comprehensive home care and hospice programs, fitness and wellness centers, retail pharmacy services, a medical group, multi-site imaging centers and an accountable care organization.
RWJBarnabas Health Medical Group is a multispecialty group practice comprised of highly trained and experienced world class primary and specialty care physicians. RWJBarnabas Health Medical Group physicians provide compassionate and innovative cutting-edge care for people at every stage of life at easily accessible facilities conveniently located throughout New Jersey. Backed by the vast continuum of resources of RWJBarnabas Health, the largest not-for-profit integrated health care delivery system in New Jersey and one of the largest in the nation, our dedicated physicians and expertly trained supporting staff continuously strive for clinical excellence.
We offer a great work environment, competitive rates and excellent benefits, including:
- Medical/Dental/Vision plans
- 401 (k)
- Short & Long Term Disability
- Basic Life & Accidental Death Insurance
- Tuition Reimbursement
- Health Care/Dependent Care Flexible Spending Accounts
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