DIR MGD CARE CONTRACTING

Overview

Managed Care Director, Managed Care

Full Time, 80 Hours Per Pay Period, Day Shift

Covenant Health Overview:

Covenant Health is the region’s top-performing healthcare network with 10 hospitals, outpatient and specialty services, and Covenant Medical Group, our area’s fastest-growing physician practice division. Headquartered in Knoxville, Covenant Health is a community-owned integrated healthcare delivery system and the area’s largest employer. Our more than 11,000 employees, volunteers, and 1,500 affiliated physicians are dedicated to improving the quality of life for the more than two million patients and families we serve every year.

Covenant Health is the only healthcare system in East Tennessee to be named a Forbes “Best Employer” seven times.

Position Summary:

In conjunction with others in the Managed Care Department, this position is responsible for coordinating the contract management process for all managed care contracts for Covenant Health. This includes, but is not limited to, assisting in the development of strategic plans, leading contract negotiations, frequent communications with operation and business office leaders, ensuring contract compliance, assisting to resolve payment or other payer problems, internal dissemination of contract terms, etc. This position requires an individual to be competent in understanding provider contractual relationships, reimbursement methodologies, member benefit plans and to oversee all aspects of the contracting process and third-party audits per established guidelines. This position requires strong analytical and financial skills as well as solid leadership, communications and interpersonal skills. Position also requires an individual who is comfortable managing multiple projects simultaneously. This position calls for a “self-starter” who is comfortable with a high degree of autonomy and is capable of independent thinking/planning and using good judgment in decision making.

This position services as a liaison between the Managed Care Department and other Covenant Health and facility departments. Position works with patient account departments to solve significant payer issues and is responsible for maintaining relationships and communication with contracted payers. Position will conduct periodic meetings with major payers to discuss and resolve identified issues and will ensures providers, payers and prospective patients receive prompt, understandable updates on information which concerns participation in plans as needed.

This position is responsible for oversight of the Credentialing Verification Office (CVO) and Payer Enrollment. This includes strategic planning, issues resolution, cross-training planning, and linkage to system Director of Quality Analytics/ Accreditation and Medical Services Specialist, or other system credentialing contacts, as assigned.

In addition, this position serves as a liaison between the Managed Care Department and other Covenant Health and facility departments.

Recruiter: Kathleen Rice || kkarnes@covhlth.com || 865-374-5386

Responsibilities

Supervision:

Position reports to: Senior Vice President of Business Development & Managed Care.

Position supervises: Managed Care Specialist and Credentialing Verification Office (CVO) Operations Manager. 

Position Accountabilities and Performance Criteria:

• Assist Senior VP of Business Development & Managed Care in the revision of managed care strategic plan(s).
• Establish good working relationships with operation and business office leaders, joint venture operations and physician leaders, senior management, payers, etc.
• Following strategic priorities, oversee and coordinate the contracting process for third-party payer contracts per established guidelines.
• Assist in education with physician groups to ensure participation in like plans.
• Ensure payers and providers comply with all contract terms, such as annual rate updates, term notices, etc.
• Develop and dissemination reports/updates and conduct or participate in education and training sessions with key internal ‘customers’ and payers.
• Maintain regular contact with operations leaders and third-party payers to assure system developments and new services are communicated and future market changes are anticipated.
• Assist in the resolution of payment or other problems/issues with payers.
• Train department on Managed Care Online or other database tools, and serve as back-up loader.
• Coordinate and/or assist in scheduling and participate in case management, business office or other needed meetings with third party payers.
• Oversee and be involved (as needed) with 3rd party payer audits. Ensure audits are performed per audit policy/procedure and contract terms.   Ensure any trends, issues, concerns or recommendations for improvement ‘discovered’ during audits are shared and communicated throughout the System as appropriate.
• Maintain current knowledge of changes affecting government contracts and reimbursement trends including Medicare, TennCare, etc.
• Oversee the Managed Care Contracting Specialist, who coordinates and maintains contracts for Covenant Medical Group and Covenant Health JV Surgery Centers.
• Oversee the Credentialing Verification Office (CVO) Operations Manager who supervises the managed care payer enrollment process for the Covenant facilities and Covenant employed/contracted physicians, including facility payer enrollment, group and individual physician payer enrollment, behavioral health provider payer enrollment, hospital-billed physician payer enrollment.
• Oversee the Credentialing Verification Office (CVO) Operations Manager who supervises the Credentialing Verification Office functions of system credentialing verification, Cactus credentialing system, and liaison to the system Medical Staff Offices.
• Develop cross-training program for departmental staff coverage needs, together with the Credentialing Verification Office (CVO) Operations Manager.
• Maintain professional growth and development through seminars, workshops and professional affiliations to keep current with latest trends in the field.

Qualifications

Minimum Education:

Bachelor’s degree in business or other relevant field required.  Master’s degree is preferred. 

Minimum Experience: 

At least five to ten (5-10) years of related experience is required.  Individual must have a solid fundamental understanding of managed care contracting, enrollment and provider (hospital, physician, ancillary, etc.) reimbursement.  “Hands-on” experience with general provider operations,  medical coding and billing systems, regulatory and policy compliance issues relating to government healthcare programs such as Medicare and knowledge of ICD-10, CPT and HCPCS coding is required.  Experience with contract negotiations is a must.  This position requires strong analytical and financial skills as well as solid leadership, communications and interpersonal skills.

Licensure Requirements: 

None