Director, Managed Care Operations
Apply NowCompany: Pediatric Associates
Location: Plantation, FL 33388
Description:
Pediatric Associates was founded in Hollywood, FL in 1955. The same clinician-led, evidence-based, medical home passion is a unifying driver for those who join Pediatric Associates Family of Companies. The Pediatric Associates Family of Companies is a growing team of Pediatricians and Pediatric Care Teammates who are excited to be part of the first nationwide Pediatric Primary Care Medical Home. We further our uniqueness by ensuring the clinician voice is leading our medical home innovations.
PRIMARY FUNCTION
The Director, Managed Care Operations is responsible for establishing and maintaining the day-to-day operations of managed care's operations. This position is the primary point of contact and will track and escalate all payor issues in relation to all payor contracts. This position works closely with the Directors of Payor Relations and directly reports to the Senior Vice President of Payor Relations.
ESSENTIAL DUTIES AND RESPONSIBILITIES
This list may not include all of the duties that may be assigned.
Manages and establishes department tools, policies, and procedures to ensure workflow efficiencies, updates, and dissemination of payor information. Collaborates with Payor Relationship Managers to monitor acquisition workflow for all PAFC Acquisitions. Collaborates with Payor Relations to resolve Incentive Payment issues which include Capitation, Gainshare/Risk, Pay for Performance, and other Payment arrangements. Evaluates current contracts and create proposals for new negotiations and renegotiations including Risk, Value Based, Fee for Service, and Payor Specific contracts in conjunction with the Directors of Payor Relations. Leverages internal departmental relationships to ensure contract workflows are established and maintained. Manages and develops the Managed Care Operations Team. Implements tools to monitor and ensure Payor and Provider compliance with contract terms in accordance with state and federal regulations based on each individual markets. Establishes and monitors contract renewal schedule to ensure contracts are negotiated in a timely manner. Other duties as assigned.
SUPERVISORY RESPONSIBILITIES
QUALIFICATIONS
EDUCATION:
Bachelor's degree in Healthcare related field or Business preferred.
A minimum of 5 years of related experience will be commensurate with education.
EXPERIENCE:
KNOWLEDGE, SKILLS AND ABILITIES
TYPICAL WORKING CONDITIONS
OTHER PHYSICAL REQUIREMENTS
PERFORMANCE REQUIREMENTS
Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI (Protected Health Information) in accordance with organizational policy, Federal, State, and local regulations.
The Pediatric Associates Family of Companies an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
PRIMARY FUNCTION
The Director, Managed Care Operations is responsible for establishing and maintaining the day-to-day operations of managed care's operations. This position is the primary point of contact and will track and escalate all payor issues in relation to all payor contracts. This position works closely with the Directors of Payor Relations and directly reports to the Senior Vice President of Payor Relations.
ESSENTIAL DUTIES AND RESPONSIBILITIES
This list may not include all of the duties that may be assigned.
SUPERVISORY RESPONSIBILITIES
- Manages and develops Managed Care Operations Team. Provides ongoing training, performance feedback, and avenues for professional development.
- Establish Team Goals and team performance KPIs
QUALIFICATIONS
EDUCATION:
Bachelor's degree in Healthcare related field or Business preferred.
A minimum of 5 years of related experience will be commensurate with education.
EXPERIENCE:
- Minimum of 6 years' of combined payor and provider experience required.
- Previous healthcare experience required.
KNOWLEDGE, SKILLS AND ABILITIES
- In-depth understanding of contract parameters, reimbursement methodologies, contract language and performance.
- Knowledge in Risk and Value Based Contracting
- Effective strategic planning and organizational skills
- Knowledge of Statewide Medicaid Managed Care programs and Commercial payors
- Proficient in research, analysis, and interpretation of financial data and trends
- Knowledge of reimbursement methodologies and CPT, ICD10, RBRVS, and capitation.
- Knowledge of claims, credentialing, and loading processes
- Advanced Microsoft Office skills
- Effective oral and written communication and negotiating skills.
- Ability to manage multiple priorities and projects.
- Strong interpersonal skills
- Ability to influence others
TYPICAL WORKING CONDITIONS
- Non-patient facing
- Full time remote.
- Must be U.S. based.
- Indoor Work
- Operating Computer
- Reach Outward
- Reach above Shoulder
- Lift/Carry 11-20lbs.
- Standing
- Sitting
- Traveling
- Walking
- Bending
- Manual Dexterity
OTHER PHYSICAL REQUIREMENTS
- Vision
- Sense of sound
- Sense of touch
PERFORMANCE REQUIREMENTS
Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI (Protected Health Information) in accordance with organizational policy, Federal, State, and local regulations.
The Pediatric Associates Family of Companies an Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.