SENIOR DIRECTOR MANAGED CARE

Job Overview:

Director Managed Care 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 TriHealth. Additionally, this individual will participate in and support the development of managed care strategies with senior executives, leading to initiatives for TriHealth to adapt to address ongoing healthcare payment reforms and evolving payment methodologies, including - but not limited to - accountable care organizations (ACOs) and clinically integrated networks (CINs). The leader will foster professional relationships with payor executives and serve as a liaison between TriHealth and payors. This individual will also be responsible for representing the interests of TriHealth in discussions related to managed care and all aspects of the day-to-day operations of managed care, including the development and oversight of managed care staff. The ideal candidate is a highly valued partner within TriHealth, working collaboratively across the organization.

Job Requirements:

Bachelor's Degree business, healthcare administration, or related field (Required)
7 - 10 years experience Management in managed care environment, health insurance industry, or managed care Product development/negotiations (Required)
Payor relations 
Managed care ops 
Fee schedules 
Traditional, value-based, and innovative payment model terms and structures 
Payer denial management 
Maintaining, fostering and developing employer relationships 
Developing and monitoring payor scorecards 
Lead and direct JOCs 
Lead and support Population Health Initiatives 
Strategic alliances with internal customers 
Ability to work in collaboration with senior leaders, advising on strategic decisions 
Development and oversight of managed care team (recruiting/re-recruiting) 
Content expert for internal/external departments for all managed care terms and strategies

Job Responsibilities:

Leads Health System's participation with managed care plans, with responsibility for execution and delivery of new opportunities and proposals with respect to Health System's contracting strategy and contracting and financial standards o Serves as a leader of the managed care team, providing strategic direction on managed care related issues o Leads the development of the Health System’s managed care relationships, including establishment of clear and effective plans for growth, negotiation, reimbursement structure, contract renewal planning process, and contract implementation o Reviews and responds to new payor proposals in line with Health System managed care strategy o Serve as the lead contract negotiator with payors, including Commercial, Medicare Advantage, and Managed Medicaid o Achieves results in line with budgeted and forecasted performance and growth requirements as set forth by Health System leadership o Partners with Health System revenue cycle, clinical, and operational teams to identify impacts and implement new contracts/products o Supports the education of revenue cycle, billing, and coding staff on changes in contract terms, policies, and procedures o Evaluates existing and proposed payor contract language against best practice and evaluates impact of any new proposed contract language 
Guides efforts to meet Health System's payor contracting objectives. Partners and participates in activities of others throughout Health System as needed to achieve objectives o Stays current with emerging payor trends, new reimbursement methodologies, national regulatory issues, plan benefits, payor activity, products and delivery channels including health insurance exchanges, market competition, etc. o Identifies opportunities and takes action to build strategic relationships between managed care and other areas, teams, department, or organizations to help achieve business goals o Works effectively in a matrixed environment, integrating and aligning with revenue cycle, credentialing, and operations teams and maintaining positive relationships and utilizing effective problem-solving skills o Lead joint operating committees (JOC) with contracted payors on a regular basis to discuss operational and administrative issues and develop and enhance the relationships between the parties o Follows up and resolves problems related to payor contracting in a timely manner o Provides regular status updates to leadership on progress and unresolved issues. o Supports the creation of annual payor contract renewal cycle timeline to effectively plan for upcoming contract renewals 
Provides Oversight and management to managed care department. Performs other managed care related activities as needed o Oversees human resource management for managed care creating a culture of employee engagement. o Ensures appropriate structure and delegation of functions within the managed care department. o Participates in professional activities and maintains professional affiliations as appropriate o Resolves issues and problems and makes a significant contribution to team efforts o Performs all projects within the required timeframe. 
Embraces technological solutions to work processes and practices o Utilizes billing vendors and billing systems to gather and analyze information. o Utilizes Microsoft Excel, PowerPoint, and Word proficiently. o Assists in development and implementation of a contract management database o Participates in continued learning and possess a willingness and ability to learn and utilize new technology and procedures that continue to develop in their role and throughout the organization. o Embraces technological advances that allow us to communicate information effectively and efficiently based on role. 
Leads by and exemplifies the TriHealth Way of Leading in all interactions

Working Conditions:

Bending - Rarely 
Climbing - Rarely 
Concentrating - Frequently 
Continuous Learning - Consistently 
Hearing: Conversation - Frequently 
Hearing: Other Sounds - Frequently 
Interpersonal Communication - Consistently 
Kneeling - Rarely 
Lifting Pulling - Occasionally 
Pushing - Occasionally 
Reaching - Occasionally 
Reading - Frequently 
Sitting - Frequently 
Standing - Frequently 
Stooping - Rarely 
Talking - Consistently 
Thinking/Reasoning - Consistently 
Use of Hands - Frequently 
Color Vision - Frequently 
Visual Acuity: Far - Frequently 
Visual Acuity: Near - Frequently 
Walking - Frequently

Leadership Performance Standards

TriHealth leaders create a culture of engagement, safety & reliability and high performance by consistently modeling and utilizing the following TriHealth Way leadership competencies, tactics and ALWAYS Behaviors to drive strategic pillar results:

Achievement of Annual Pillar Goals: 
1) Safety/Quality, 2) Service, 3) Growth, 4) Culture/People, 5) Finance

Leadership Competencies: 
TriHealth Way of Leading 
TriHealth Way of Serving 
Transformation Change 
Drive for Results 
Build Organizational Talent

Leadership Tactics: 
Conduct department huddles. Generally, clinical departments hold daily huddles, non-clinical hold weekly huddles. 
Regularly Round on Team Members, using questions from the rounding log. 
- 25 or fewer team members = monthly 
- 26-50 team members = every other month 
- 51+ (and optional team members) = quarterly

Lead monthly team meetings using meeting agenda template; review stoplight report; cascade key leadership messages.

Model, coach and validate team members use of TriHealth Way behaviors (AIDET + Promise, Always Behaviors and Always HEARD).

Recognize team members for safety wins, positive performance and demonstrating SERVE and ALWAYS behaviors, TriHealth Way of Leading, Serving and Delivering Care.