Manager-Managed Care Operations

About The Role

The Managed Care Operations Manager assists with day-to-day Managed Care operations and contracting activities. Monitors and updates Director of Managed Care Operations on political, legal and regulatory trends with respect to managed care and vertical integration. Works with Medical Economics to support contract management / EPIC system build, Finance and Revenue Cycle to produce reports concerning managed care contract performance. This position will work with the various Revenue Cycle components to ensure accurate interpretation and application of managed care contract terms / structures, etc. This position will work as a liaison between managed care payers and NGHS staff to facilitate resolution of contractual and operational issues in order to enhance managed care contract performance.

Minimum Job Qualifications

Licensure or other certifications : EPIC Resolute Hospital Billing Reimbursement Contracts Management (certification preferred)

Educational Requirements : Bachelor's Degree

Minimum Experience : 2 years of managed care or healthcare finance / revenue cycle experience.

Other : In lieu of a degree, will consider individuals with a minimum of six (6) years of managed care contracting and / or related managed care experience.

Preferred Job Qualifications

Preferred Licensure or other certifications : Certification.

Preferred Educational Requirements :

Preferred Experience :

Other :

Job Specific and Unique Knowledge, Skills and Abilities

Possess extensive knowledge of the Managed Care environment in Georgia or similar market

Possess successful relationship building skills

Self motivated with strong organizational and planning skills

Good written communication skills including email

Deep knowledge of contract management system(s) build and the mechanisms necessary to calculate accurate contract reimbursement

Excellent analytical skills through use of various spreadsheet software (i.e. excel), querying software, and / or contract mgmt. programs

Essential Tasks and Responsibilities

Assist with research, analysis and negotiation of assigned contractual agreements. Attend meetings with representatives of Managed Care Organizations, as required, gathering information on their market presence and future development. Assist with the review of managed care contract language to achieve optimal reimbursement for NGHS and to promote internal efficiencies among internal departments that are affected by said contracts. Assist with service specific reviews of volume and pricing in an effort to maximize contract performance. Assist with the administration / management of contracts through NGHS system, ensuring the dissemination of appropriate contract information to necessary internal / external users. Work with decisions support area (Medical Economics) and reimbursement to produce reports for the Executive Director concerning managed care contract modeling and performance. Assist decision support area (Medical Economics) with building and auditing contracts in EPIC (E.H.R. system) and other Contract Management systems. This requires EPIC certification and continuing education to retain certification.

Serve as the day to day operational contact point with all contracting parties. Field and filter day to day calls and emails from contracting parties. Serve as the conduit for managed care payer related issues between NGHS and its contracted payers. This process includes leading regularly scheduled joint operations committee meetings between the payer and key NGHS stake holders. This process involves validating claim issues, presenting the issues to the payer, following up with the payers for resolution, and providing updates and communication to the Revenue Cycle. Assist with the addition of new facilities, new physicians and new services to managed care contracts.

Serve as a liaison between various NGHS departments and Managed Care Operations. Field and filter day to day calls and emails from NGHS departments. Improve overall Managed Care integration into the NGHS organization through communication. Assist with communication and education of physicians to ensure most accurate administration of contracts and efficient NGHS operations. Assist with communication and education of staff to ensure most accurate administration of contracts and efficient NGHS operations. Work with Revenue Cycle to create and oversee the accuracy of the insurance plan code process for the patient information system as well as the contract management system. Review and disseminate payer newsletters and policies for potential operational and / or financial impact to the NGHS organization. Assist Health Partners (PPO Network) when needed for contracts through HP2. Research and provide support to NGHS departments for contractual related inquires.

Assist with the development and monitoring of managed care contracts. Develop and evaluate reports regarding the managed care contract performance and payment variances. Supervise managed care reimbursement analyst review function. Train and provide continuing education to the managed care reimbursement analyst review team. Produce and analyze payment variance trends from contract management system and EPIC contract management. Provide monthly performance reports to managed care senior leadership. Provide feedback to Revenue Cycle and other NGHS Departments regarding payment / denial trends.

Physical Demands

Weight Lifted : Up to 20 lbs, Occasionally 0-30% of time

Weight Carried : Up to 20 lbs, Occasionally 0-30% of time

Vision : Heavy, Constantly 66-100% of time

Kneeling / Stooping / Bending : Occasionally 0-30%

Standing / Walking : Occasionally 0-30%

Pushing / Pulling : Occasionally 0-30%

Intensity of Work : Frequently 31-65%

Job Requires : Reading, Writing, Reasoning, Talking

Working at NGHS means being part of something special : a team invested in you as a person, an employee, and in helping you reach your goals.

NGHS : Opportunities start here.

Northeast Georgia Health System is an Equal Opportunity Employer and will not tolerate discrimination in employment on the basis of race, color, age, sex, sexual orientation, gender identity or expression, religion, disability, ethnicity, national origin, marital status, protected veteran status, genetic information, or any other legally protected classification or status.