Director of Managed Care

PURPOSE AND SCOPE:

Directs organization's activities of strategic planning, evaluation, coordination, and implementation of various managed health care programs (HMOs, PPOs, POS, etc) in the state of California.

Oversees Division's contractual relationships with managed care organizations and other third party payors regarding rate structures for services, clinical and financial reporting obligations, establishment of other business terms per the FMCNA Guidelines, contract maintenance such as facility list updates and amendments.

Develops and directs regional marketing efforts to third party payors in order to support growth and profitability in the region.

PRINCIPAL DUTIES AND RESPONSIBILITIES:


* Manages the tactical execution of short- and long-term objectives through the coordination of activities with a direct responsibility for results, including costs, methods, and staffing.


* Reviews and analyzes potential contracts for financial effect, cost benefit and utilization.


* Negotiates contractual relationships with managed care organizations and other third party payors as needed.


* Presents contract proposals and market and industry analyses to internal parties and responds to Requests for Proposals from third party payors.


* Manages activities concerned with contracts for delivery systems.


* Works on issues where analysis of situations or data requires an in-depth knowledge of organizational objectives.  Has significant project/process responsibility within the function.


* Interprets company-wide policies and procedures.

Involved in the development, modification and execution of company policies that affect immediate operations with potential company-wide effect.

Implements strategic policies when selecting methods, techniques, and evaluation criteria for obtaining results.


* Ensures compliance of facilities with all managed care organization requirements ensures credentialing processes are implemented.


* Ensures all facilities meet and maintain appropriate credentialing requirements and licenses.


* Develops and implements methods and procedures for monitoring work activities and informs management of current work activity status.


* Responsible for continuous communication and coordination of all required ongoing documentation with appropriate staff.


* Works with internal and external counsel as needed to resolve issues and support FMS.


* Negotiates and implements contracts with payors that require clinical and quality outcomes measurements.


* Contributes to the design and implementation of third party payor compensation structures.


* Assists in the development of report cards that can be shared with third party payors illustrating outstanding quality of patient care through associated outcomes.

Ensures quality outcomes are reported accurately and in a timely manner.


* Assists with designing Quality Improvement Projects that will improve outcomes in faciliti...