Verda Healthcare, Inc. has a contract with the Center of Medicaid and Medicare Services (CMS) and Texas Department of Insurance (TDI) for a Medicare Advantage Prescription Drug (MAPD) plan for 2024. We are looking for a Manager, Provider Contracting (MPC) to join our growing company with many internal opportunities.
Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc. is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.
Align your career goals with Verda Healthcare, Inc. and we will support you all the way.
Position Overview
The Manager, Provider Contracting (MPC) is responsible for compiling, analyzing, and validating reimbursement data to aid in contract negotiations with independent physician associations (IPA), hospitals, and ancillary providers, that result in high quality, cost effective, and marketable providers. In addition to gathering volume data and modeling of current reimbursement, the MPC determines the need for methodology changes and proposes target rates benefiting Verda Health Plans.
The MPC is responsible for day-to-day operations for all activities related to contracts, contract optimization, implementation of new programs and to assist with provider issues, education materials, as well as creation and managing plan policies and procedures. The MPC will work collaboratively with other departments to resolve escalated provider issues, including grievances, disputes, and provider billing complaints.
In this role, you will need to be able to thrive in a demanding, intense, fast-paced environment. In addition, you’ll be driving some complex negotiations while striving to ensure accuracy. You will be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.
Job Description
- Advises Director of Contracting and Leadership on negotiation of IPA provider groups, facilities, routine ancillary contracts.
- Develops and executes negotiation strategies to benefit and protect the company’s interests
- Analyzes financial impact of contract and terms
- Assesses contract language for compliance with corporate standards and regulatory requirements and review revised language with assigned Verda attorney.
- Participates in risk base, capitation, and fee schedule determinations including development of new reimbursement models. Seeks input on new reimbursement models from Corporate Network Management and legal.
- Participates on the management team and other committees addressing the strategic goals of the department and organization.
- Evaluate and negotiate contracts in compliance with company templates, reimbursement structure standards and other key process controls
- Recommend deviations from standards
- Participates in the evaluation of provider network and implementation of strategic plans to meet Verda's network adequacy standards.
- Manages contract performance in support of network quality, availability, and financial goals and strategies.
- Collaborates cross-functionally to contribute to provider compensation and pricing development activities and recommendations, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities.
- Responsible for identifying and making recommendations to manage cost issues and supporting cost saving initiatives and/or settlement activities.
- Ensures resolution of escalated issues related, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.
- Interprets contractual requirements including federal and state regulations and NCQA.
- Participates in JOC meetings
- Special Project as assigned
- Ability to travel
Minimum Qualifications
- Bachelor's Degree healthcare related field or an equivalent combination of education and experience.
- Master’s Degree or equivalent preferred
- 5+ years of experience in managed care/health care industry
- 4+ years of experience with provider contracting/HMO model including, knowledge of Division of Financial Responsibility (DOFR), risk pool, development of product pricing, and utilizing financial modeling in making rate decisions
- In-depth knowledge of Medicare Resource Based Relative Value System (RBRVS), DRGs, Ambulatory Surgery Center Groupers, etc.
- Experience with bundled payment contracting or risk and capitation required
- An understanding of healthcare financing, access issues, and legislation
- Working knowledge of competitor strategies, complex contracting options, value-based contracting, financial/contracting arrangements, and regulatory requirements.
Professional Competencies
- Proficient in Microsoft Suite (Excel, Access, PowerPoint, Project, Outlook, Word, etc.)
- Knowledge of medical terminology, ICD-10, CPT and HCPCS.
- Understand all relevant payment methodologies, including but not limited to Medicare, RBRVS, DRG, APR-DRG, OPPS, Per Diems, Capitation, and Case Rates.
- Strong analytical skills with the ability to collect, organize, analyze, and disseminate significant amounts of information with attention to detail and accuracy.
- Understands and can construct financial responsibility tables and check for accuracy against Health Plan Documents.
- Ability to manage and prioritize multiple tasks, promote teamwork and fact-based decision making
- Excellent communication skills
- Ability to work independently and within a team environment
- Familiarity of the healthcare field
- Critical listening and thinking skills
- Decision making/problem solving skills
- Demonstrated progression of leadership and responsibility
- Ability to work in a fast-paced, start-up culture
- Proven ability to build, develop, and lead strong teams of operators