Director Managed Care Resume Sample
Emmy Bruen
74425 Beulah Tunnel,
Chicago,
IL
+1 (555) 923 1997
Work Experience
Director, Managed Care Contracting
12/2015
-
PRESENT
Chicago, IL
- Ten years of progressive related work experience in managing the managed care function, with at least three years of prior managerial level work experience
- Knowledge in Medicare risk contract compliance as well as DOC/DOI interfaces
- Extensive knowledge and experience in a managed care environment
- Knowledge of specialized software and systems related to departmental operations, including IDX
- Knowledge of departmental operations, and organizational policies, processes and procedures
- Demonstrated successful managerial experience in managing large claims production shops in a service center environment
- Effectively lead large operational departments in a matrix environment
- Time management skills to handle multiple, competing demands and priorities, and work effectively under pressure
Director Managed Care
07/2011
-
06/2015
Boston, MA
- Budgeting and financial knowledge and skills for tracking departmental and division profitability
- Mathematical skills including the ability to calculate figures and amounts such as discounts, interest, commissions, and percentages
- Team building, communication skills including: oral, written, and presentation, negotiation skills, flexibility in fast-paced, dynamic environment
- Management skills to establish priorities, and to effectively supervise and develop assigned staff to attain optimum skill and performance levels
- Human relations skills to build effective working relationships with staff, customers, and community groups and individuals
- Responsible for leading and directing Managed Care activities on behalf of all Orlando Health facilities and affiliated/owned ancillary providers in accordance with corporate market share, financial, and community-focused goals and objectives
- This entails a market and financial analysis, legal contract review, contract language and rate negotiations/re-negotiations, contract implementation and maintenance, health plan delegated credentialing, and ongoing support of the client relationship
- Establishes and maintains a strong, open and positive working relationship with external Managed Care plan executives and team members, employers, physicians, Orlando Health executives and team members, patients/customers, and the Orlando community
Director, Managed Care, Physician Services
05/2005
-
04/2011
Chicago, IL
- Works with newly acquired facility and ancillary providers to facilitate integration of Managed Care contracts
- Responsible for the selection and retention of staff who meet high standards of performance as well as possessing exceptional team and standards of behavior
- Mentors and encourages professional development of team members
- Develops and implements operational plans consistent with the overall corporate goals and objectives. Establishes a system for variance control
- Provides input, recommendations, and actively participates in development of corporate strategic plans and Managed Care contracting decisions
- Establishes Critical Success Factors for Managed Care contracting, in conjunction with corporate Critical Success Factors
- Consistently monitors and takes corrective action to ensure standards are met or exceeded
- Participates with management, medical staff, and clinical areas in Orlando Health's decision making structure and process
- Functions as a resource to Orlando Health management and physician community by providing timely and accurate Managed Care Orlando market and contract information to assist in the full accomplishment of their goals and objectives
Education
Everest University - Largo Campus
2001 - 2005
Bachelor's Degree in Business
Professional Skills
- Strong presentation skills and excellent negotiation, sales, analysis, communication, and PC skills
- Prior contracting experience contracting in a pediatric health care setting is strongly desired
- Strong problem solving, listening, staff development and time management skills
- Strong organizational and written/oral communication skills, including the ability to tailor communications specifically for the intended audience
- Excellent written, verbal, and assessment skills
- Excellent customer relationship/management skills
- Pharmacist CE Program development and presentation skills
How to write Director Managed Care Resume
Director Managed Care role is responsible for health, compensation, negotiation, reporting, retail, finance, credit, training, database, design.
To write great resume for director managed care job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Director Managed Care Resume
The section contact information is important in your director managed care resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Director Managed Care Resume
The section work experience is an essential part of your director managed care resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous director managed care responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular director managed care position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Director Managed Care resume experience can include:
- Maintains, revises, and implements changes in policies and procedures to meet all licensing agency requirements, such as Joint Commission, local, state, and federal regulatory agencies
- Analytical skills to collect information from diverse sources and summarize the information and data in order to solve problems
- Responsible for the directing utilization management, complex care case utilization, and effective transitions in care
- Maintains strong relationships with Managed Care organizations
- Lead the managed care staff to support contract operations, evaluate market opportunities, and maintain effective processes to support internal consumers
- Preparing internal training or educational tools as they related to health plan contracting and/or
Education on a Director Managed Care Resume
Make sure to make education a priority on your director managed care resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your director managed care experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Director Managed Care Resume
When listing skills on your director managed care resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical director managed care skills:
- Strong management, organizational, interpersonal, communication, teaching and presentation skills
- Creating and providing effective and influential communications to facility clients and operations; and
- Familiar with patient accounting tasks including billing, collections, and reimbursement analysis; strategic planning and marketing experience
- Prioritize work efforts, including personal as well as subordinates’ efforts, without sacrificing work quality or timeliness of completion
- Prioritize work efforts, including personal as well subordinates’ efforts, without sacrificing work quality or timeliness of completion
- Experience with pay-for-performance and/or shared risk contracting
List of Typical Experience For a Director Managed Care Resume
1
Experience For Director, Managed Care Contracting Resume
- Working knowledge of strategic and consultative selling techniques and related information
- Positively influence the activities of others, including coaching, training, and guiding
- Deep expertise and well versed in hospital and physician managed care term and rate negotiations, contract review and strategic planning and pricing
- Negotiate/administer special pricing reimbursement rates and relationships as needed
- Develops and monitors budget and takes corrective, as necessary, to resolve variances
- Keeps abreast of current issues and trends in the Managed Care environment on the local, state, and national levels
- Supports all established policies, procedures, goals and objectives of Orlando Health
2
Experience For Director, Managed Care Resume
- Participates in Managed Care associations to keep abreast of current issues and trends
- Provide oversight or direct negotiating in all Managed Care negotiation and contracting activities consistent with the Managed Care strategies, business and financial plans
- Lead significant dollar and volume contracts negotiations, and oversee proper supporting Managed Care Data, Information, and Financial Systems to be provided in the formats to align with strategic and operational insights required for a beneficial negotiation
- Negotiate contracts with Managed Care payers and governmental entities on behalf of all Lifepoint facilities including legal language review, proposal of rates, reimbursement methodologies, and review of any state regulations or federal regulations
- Direct and provide financial analysis to support contracting efforts and issue resolution to include the use of PIC forecaster Models, Excel Models and other tools available to assess contracts or revenue recovery opportunities
- Analyze and monitor financial and operational aspects of existing Managed Care Contracts for use in making rec-ommendations on renewals, renegotiations or terminations
- Cultivate and maintain professional relationships with all third parties and/or vendors to promote proactive prob-lem resolution
3
Experience For Director, Managed Care, Physician Services Resume
- Research state and federal regulations as they change for payers and educate Lifepoint Health Support Center (HSC) departments and facilities on the impacts of these changes to reimbursement and processes
- Manage the implementation of completed contracts including dissemination of the contract to relevant parties, explanations of new items in the contract, ensure contract has been scanned, filed and logged in Lifepoint files
- Maintain an open flow of communication with Government Relations and the Reimbursement Department on state and federal changes that necessitate the negotiation of new contracts and/or mandated changes in reimbursement at facilities
- Exhibit a comprehensive understanding of healthcare regulatory and compliance (e.g., HIPAA). Skilled in the application of policies and procedures. Knowledge of Business Office Standards and Recommended Practices
- Directs and manages the department in a fiscally responsible manner in compliance with organizational and departmental policies and procedures
- Engages key ancillary, nursing and medical staff departments in the identification of barriers & barrier resolution to ensure efficient, effective and safe care coordination occurs
- Works collaboratively with the Medical Director on activities, including Physician Advisor effectiveness, clinical documentation opportunities, identification of barriers and barrier resolution impacting throughput, physician and patient satisfaction with utilization admission process, data management and complex case utilization
- Builds solid relationships and service level agreements with OHS payers to reduce avoidable day's secondary to payer authorization delays
4
Experience For Director, Managed Care-st Mary Med Center Resume
- Champions and leads efforts to implement best practices and innovation within hospital operations to facilitate reduction in catastrophic patient days, canceled admissions, and technical denials
- Oversees Managed Care team’s book of business, to include regular reporting on contract performance, new revenue generation and revenue growth, to meet or exceed established targets
- Evaluates and recommends financial parameters and reimbursement methodologies
- Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance initiatives
- Initiate contact with Managed Care Plans to begin negotiation/re-negotiation process
- Develop and manage a portfolio of payer contracts that optimize organization revenue, margin and growth in alignment with CHI’s mission and strategic objectives
- Negotiates successful contracts with Managed Care organizations
- Plans and oversees education for Patient Financial Services (PFS) and applicable Revenue Cycle departments throughout the system in order to educate departments concerning contract terms, language and compliance
5
Experience For Director, Managed Care Access Resume
- Develops skills and provides focus on the market conditions/changes including but not limited to consumerism, value based healthcare, transparency, risk contracting, etc
- Calculate net revenue on all Cyberknife cases for the month and compile related information for the month on the Cyberknife revenue analysis workpaper. Also calculate net revenue on all open accounts in the AR for Cyberknife cases and compile the journal entry to book all adjustments related to those accounts
- Prepare the AR net down work paper for the month for both inpatient and outpatient for DCMH
- Prepare variance reports for all hospital entities with explanations on both inpatient and outpatient revenue for the month
- Provide net revenue calculations as requested for various services
- Evaluate client agreements with managed care payers and propose revisions to terms and conditions intended to improve net revenues and diminish or mitigate payment risk. Evaluate payer agreements for rate sufficiency and proposed alternate rates or rate models intended to improve net revenue. Negotiate on client’s behalf directly with payers
- Preparing reports and presentations to monitor portfolio performance, yield, payer mix, etc
- Review, analyze, and assist with negotiations of Pharmacy Benefit Manager and Health Plan pharmacy reimbursement contracts
6
Experience For Senior Director Managed Care Analytics Resume
- Interact directly with Pharmacy Benefit Manager and Health Plans to resolve issues and clarify contract language and payment terms
- Maintain relationships with major managed care organizations and Pharmacy Benefit Managers (PBMs) for the purposes of continued and new contracting, increasing revenue, and building business opportunities
- Provide enhanced reporting and data for the purposes of focusing corporate pharmacy initiatives and directing pharmacy performance improvement (e.g., quality and performance programs, generic dispensing and formulary compliance, etc.)
- Support geographic contract negotiations and underlying payer relationships
- Administration of special pricing reimbursement rates and relationships
- Onboard acquisitions, entities and locations and new provider affiliations to payer contracts
- Focus on client satisfaction through internal and external communication
- Negotiate Hospital and Physician contracts with payors in accordance with strategic objectives identified by respective Corporate Officers
7
Experience For Director / Managed Care Consultant Resume
- Analyze all market based opportunities both Commercial and Government/Fee for Service and Risk, including participation in the contract modeling conducted by the Performance Management function
- Prepare recommendations for presentation to NorthShore Senior Executive Leadership regarding market based opportunities
- Engage with NorthShore's quality and operations teams to evaluate and identify key areas of opportunity for improvement in both Value Based Care programs and other pay per performance programs
- Participate in the design of analytics to support traditional managed care activities including but not limited to contract modeling, performance evaluation and operations support
- Participate and lead efforts to expand and enhance NorthShore's capabilities around Population Health Analytics inclusive of engagements with the clinical analytics team, working with Epic, and strengthening internal analytic capabilities
8
Experience For Director Managed Care Cost Resume
- Evaluate opportunities to streamline processes to improve the evaluation of contract operations
- Serve as a point of contact for payors for contract operations as well as new programs
- Evaluates and recommends financial parameters and reimbursement methodologies
- Implements new managed care programs in conjunction with faculty, staff and hospital/practice administration. Keeps staff apprised of developments in the managed care marketplace
- Directs and participates in financial analysis of revenue projections based on contractual rates with payers, adverse trends, terms and appropriate recommendations or conclusions
- Analyze and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals, renegotiations or termination. Make recommendations regarding participation or non-participation with new or existing agreements
- Facilitates promotion of departmental programs to provider networks
- Develop and audit payer fee schedules based on negotiated reimbursement rates by contract and/or product line
- Maintain and distribute participation information by payer by network product for all signed contracts, contracts under-negotiation, or plans not being negotiated
9
Experience For Regional Director, Managed Care Contracting Resume
- Responsible for reviewing managed care legal contract language and negotiating language to meet agreed to parameters with legal counsel to lessen risk and improve operational efficiencies
- Strategic planning accountability for other reimbursement & profitability endeavors with subcontract arrangements, government programs, pay for performance initiatives
- Assembles information and prepares materials for presentation to committees, administrators and managed care networks
- Perform special projects as requested by the Vice President of Managed Care
- Initiate contact with Managed Care Plans to begin negotiation/re-negotiation process
- Coordinate with Revenue Cycle Groups to assure contract compliance and troubleshoot reimbursement issues
10
Experience For Director Managed Care Va Resume
- Develop strategies to link payment to performance and quality of the practices
- Lead geographic contract negotiations and underlying payer relationships across enterprise service lines and encompassing varied professional and ambulatory surgery center based specialties
- Create and maintain credible relationships with Operations, other stakeholders, and payers related to contract performance and contracting efforts
- Facilitate the resolution of payer issues such as provider participation, contract operations, and payment issues and payer disputes
- Assist in the development of departmental goals, executing projects to achieve these goals, and work closely with others to ensure continuous department success
List of Typical Skills For a Director Managed Care Resume
1
Skills For Director, Managed Care Contracting Resume
- Contract administration experience including 2+ years managerial experience
- Effectively work in a matrix environment where multiple and competing customer demands are likely
- Experience in health insurance payor contracting in the government market segments with a national or large Regional health insurance provider
- Ten years of progressive experience in managed care contracting, network development, physician relations and financial/utilization analysis
- Experience negotiating managed care contracts with CMS, MCOs, Medicaid and Medicare
- Developing strategies for growing and optimizing the assigned managed care portfolios
- Managing, guiding and establishing accountabilities for staff of applicable departments for MHS and OCMC/SMC in support of local and system objectives
2
Skills For Director, Managed Care Resume
- Leading payer contract negotiations, oversee contract operations, and resolve contract disputes as they arise
- Working knowledge of Georgia Medicaid regulations and procedures
- Controlling the budget for the OCMC/SMC Managed Care Department
- Monitor service and performance of accounts including billing, pricing, systems requests, payment activity, reports, etc
- Ensure the career/work development, cross training, and succession planning among the members of the team
- Facilitate the monitoring of payer issues such as provider participation, contract loading and payment issues
- Serve as a subject matter expert regarding emerging managed care initiatives
- Develop and oversee the maintenance of tools to ensure all key stakeholders are informed of contract performance and key upcoming contracting decision points
3
Skills For Director, Managed Care, Physician Services Resume
- Liaison with physician practices, hospitals, other affiliated organizations and managed care organizations regarding issues pertaining to managed care
- Catalog and organize contracts along with helping maintain contracts data base and maintaining Managed Care data base
- Prepare internal training and educational tools as they relate to health plan contracting activities and payment policies/methodologies
- Responsible for achieving assigned operating earnings and revenue objectives for all assigned large managed care accounts
- Initiate programs and processes to retain current business and grow business in each contract, including maximizing pull through opportunities
- Negotiate and implement pricing for years of coding, exclusions, and new technology
4
Skills For Director, Managed Care-st Mary Med Center Resume
- Monitor reinsurance claim recoveries; oversees required reporting of interventions with members and providers, claims run-out data & any other negotiated item
- Direct administration & operational aspects as a risk bearing network with commercial health plan(s)
- Prepare annual budget and forecast on for full and shared risk contracts. Summarize P&L performance, outlining key assumptions
- Expert knowledge of the managed care industry and its application in a hospital setting
- High integrity, including maintenance of confidential information
- Based on business need, the ability to work a flexible schedule, including some evenings and weekends
- Performs consulting services in support of our partners’ “Clients” business objectives
5
Skills For Director, Managed Care Access Resume
- This can be a remote based position when not traveling
- Provide Profit/Loss statements for new programs and/or existing programs as requested by Senior Management
- Increase pharmacy sales through strategic relationships and marketing of Rite Aid value-added services to Pharmacy Benefit Manager and Health Plans
- Negotiate new and renewing quality pay for performance programs to support organizational goals around quality improvement and cost savings
- Define and implement strategies to evaluate and report on overall payor and contract performance to position new and ongoing negotiations
- Work with the IRM Analytics Group to establish negotiating position
- Coordinate Physician contracting
- Oversee the onboarding of acquisitions, entities, and locations and facilitate new provider affiliations to payer contracts
- Work in a matrix environment where multiple and competing customer demands are likely
6
Skills For Senior Director Managed Care Analytics Resume
- Manage existing contracts to ensure contractual rates are achieved and revenues are optimized
- Evaluate the government managed care environment nationally, regionally and in local markets for the development of contracting strategy and tactics
- Develop and implement a Health Plan Audit Dashboard to track all Health Plan reports, Audits, follow-up audits, corrective action plans, and training
- Responsible for achieving annual sales and profitability targets
- Establish relationships with new and existing customers that can lead to increased revenue growth
- Identify business opportunities with new and existing customers that can be memorialized into contractual commitments
- Articulate value proposition and communicate test offerings to health plan contracting and medical teams
7
Skills For Director / Managed Care Consultant Resume
- Negotiate pricing, execution, and implementation of contracts
- Modify existing contracts to appropriately reflect operational policies, procedures and capabilities
- Responsible for models for pricing review
- Maintain regional managed care plan relationships focusing on regional anchor plan strategy
- Interact with all appropriate departments and sales personnel to ensure the proper handling and service of accounts
- When reimbursement or claims transmission and processing issues are identified, negotiate and track issues until successfully resolved
- Develop contracting strategies for governmental contracts to ensure best possible outcomes for Lifepoint facilities
8
Skills For Director Managed Care Cost Resume
- Direct the operations to support the Regional Executive Director
- Direct in the administration & operational aspects of the Network’s participation as a risk bearing network in the Hoosier Healthwise (HHW) managed care health plans for Indiana’s Medicaid population and shared risk bearing network for commercial BCBSIL HMO Plans
- Negotiate, operationalize & direct the activities relevant to the termination of any risk agreements between government and commercial health plans
- Direct activities with Network’s third party administrator for Commercial Behavioral Health
- Direct all aspects of the Network’s operations relevant to the three HIPAA Regulations of Privacy, Transaction & Code Sets, and Security. Disaster Recovery Plan current and implemented
- Develop, implement, monitor and analyze variances of a departmental performance improvement plan
9
Skills For Regional Director, Managed Care Contracting Resume
- Commitment to Mission and Values
- Managed Vision and Purpose
- Negotiates contracts with existing payers (health plans and physician organizations) based on prior contract performance, future potential and current strategic and financial goals
- Develops and enhances relationships with internal and external contacts. Proactively plan, prioritize, and communicate regarding projects, issues, and negotiations to ensure relationships are maintained and DIGNITY HEALTH's values are demonstrated on a day-day basis and when difficult business decisions need to be made
- Leads and coordinates activities of personnel in the analysis, negotiation, and management of existing managed care contracts. This includes the maintenance of a variety of activity reports in support of financial reporting as related to managed care contract performance
10
Skills For Director Managed Care Va Resume
- Coordinates implementation of HMO, PPO, and other managed care contracts with Patient Financial Services, Admitting, and Case Management; develop and maintain systems and procedures to disseminate pertinent contract information in a timely manner to appropriate regional and hospital personnel
- Knowledge of the methods and techniques used for skill and career development; ability to use these to deepen own expertise and coach, mentor and challenge others both inside and outside the organization
- Knowledge of health insurance products, market segments and marketplaces; ability to apply this knowledge to meet specific business goals and objectives
- Sufficient mobility and strength to move within the facility, as well as various environments external to the facility. Requires access to vehicle at all times during normal business hours
- Excellent written and verbal skills; negotiation skills; time management and organizational skills to be able to juggle multiple tasks simultaneously
- Strong professional and interpersonal skills to build and maintain relationships with payor, other health care professionals, and hospital management
- Strong analytical, quantitative and financial skills especially for the development of health care service compensation proposals
- Dynamic verbal and written presentation skills
List of Typical Responsibilities For a Director Managed Care Resume
1
Responsibilities For Director, Managed Care Contracting Resume
- Prepare reports and presentations to efficiently monitor and report portfolio performance, the implications of negotiation proposals, and payer dispute resolutions
- Provide input to the appropriate individuals to contribute to the development of corporate initiatives and assume responsibility for communication and execution of such initiatives
- Lead/oversee geographic contract negotiations and underlying payer relationships across enterprise service lines and encompassing varied professional and ambulatory surgery center based specialties
- Create and maintain credible relationships with Operations, other stakeholders, and payers related to contract performance, contract operations, and contract negotiations
- Experience leading a team of contracting professionals, preferably at the Director level
- Work requires between 5-8 years Physician Practice or Health Plan experience
- Physician Practice or Health Plan experience;
2
Responsibilities For Director, Managed Care Resume
- Experience with transplant or other packaged agreements
- Compliance, paralegal, or contracts management experience required
- Computer experience required (MS Word, MS Excel)
- Seven (7) years’ experience in Managed Care contract negotiations and operations
- Three (3) years’ experience in management and supervision of staff
- Prepare internal training and educational tools as they related to health plan contracting activities and, payment policies/methodologies
- Ensure superior client satisfaction through purposeful internal and external communication
3
Responsibilities For Director, Managed Care, Physician Services Resume
- Assist in the development of departmental goals, executing projects to achieve these goals; work closely with others across the enterprise to ensure continuous department success
- Prepare reports, modeling tools, and presentations to efficiently monitor and report portfolio performance, the implications of negotiation proposals, and payer dispute resolutions
- Identifies, targets, prioritizes, and implements strategies and tactics to contract with managed care plans that
- Successfully manage personnel to ensure that team, departmental and corporate goals are achieved in a timely manner
- Provide input to the appropriate individuals to contribute to the development of corporate initiatives and assume responsibility for communication and execution of corporate initiatives
- Conduct onsite visits with payers, clients, and centers that require market-specific strategies
- Conduct reviews to analyze reimbursement and contract language in Payor contracts
4
Responsibilities For Director, Managed Care-st Mary Med Center Resume
- Lead the evaluation and response to government payor RFPs
- Be the subject matter expert on government sponsored medical insurance programs and capable and testifying the Company’s position on various legislative matters
- When new contracts have been agreed, prepare signature memo, contract summary and notify appropriate departments
- Where applicable, coordinate among multiple service lines to secure optimal agreements for each specialty service. (Neonatology, MFM, Pediatric Cardiology, Anesthesia, Radiology)
- Track Medicare and Medicaid payments and program eligibility, and advocate for improved public policy, regulations, and program support
- Maintains responsibility for payer contracts with Adventist Health Physician Network, rural health clinics and other Adventist Health affiliated physician organizations
- Manages, directs, and leads the departmental staff to ensure maximum productivity and efficiency
5
Responsibilities For Director, Managed Care Access Resume
- Activities include: Directing the managed care and physician relations functions of OCMC/SMC to meet the local needs of the hospital and it’s specific marketplace
- Planning, conducting and directing negotiation of system-wide contracts with Managed Care Organizations and Ancillary Providers to maximize access to MHS Medical Centers by physicians and patients, and to maximize reimbursement to MHS and it’s Medical Centers
- Implementing activities to support system-wide strategies with physician groups including IPA development, IPA contracting, Medical Foundation, hospital based physicians and physician relations
- Participating in the Budgeting process for MHS Medical Centers to support the development of goals related to managed care revenue and expense contracts
- Develop and implement processes to ensure that all CMS required trainings (General Compliance, Standards of Conduct, HIPAA, False Claims Act, Anti-Kickback, and Fraud, Waste and Abuse, etc.) are completed timely by CHM regular and temporary staff and First Tier, Downstream, and Related Entities (FDRs)
- Manage the activities of the Audit team
6
Responsibilities For Senior Director Managed Care Analytics Resume
- Monitors and tracks reports of actual and potential health plan audit gaps through the stages of assessment, investigation, and resolution
- Development and implementation of Health Plan Risk Assessments and Corrective Action Work Plans
- Monitors and tracks the initial and monthly OIG/GSA screenings of potential and current employees and contractors who are excluded from participation in federal health care programs, including Medicare and Medicaid
- Updates Policies and Procedures for the organization, including regular reviews for updating and implementation monitoring to ensure compliance with delegated entity requirements
- Uses knowledge and experience in pharmacy managed care to act as a subject matter expert for internal and external customers
- Trains and educates sales force and customers on the need for and use of Elevate and PBA products
- Promotes customer enrollment and participation in ABC’s Elevate Provider Network services by leading our sales organization and customers in understanding the value of our solutions for independent retail pharmacy
- Partners with ABC sales organization to secure and retain new drug business in retail channel
7
Responsibilities For Director / Managed Care Consultant Resume
- Works across multiple ABC business units to promote Elevate Provider Network, win new business, and provide relevant industry updates and managed care expertise
- Drives business development and retention efforts of Elevate Provider Network services through the development of bids, proposals, contract documents, issue resolution and service coordination
- Serves as managed care liaison for buying group leadership and sales teams to promote, train and reinforce Elevate Provider Network value proposition
- Promotes the adoption and utilization of Elevate Advanced Features in partnership with internal and external vendor sales organizations
- Work across sales organization to advance customers to Premier level
8
Responsibilities For Director Managed Care Cost Resume
- Gathers information, analyzes and develops strategies to respond to changes in customer ownership, affiliations, shifts in market share, opportunities for growth, changing requirements, and competitor actions
- Sell Apria services to prospective and existing managed care clients with a focus on growing the business
- Develops business plans for the assigned book of business and account-level plans on an annual basis and refines and executes on the plan throughout the year
- Develops business relationships with key account decision makers and influencers at a Director and VP level
- Manages Apria’s relationship with the account and acts as the primary point of contact within Apria for the account
- Holds quarterly and/or bi-annual meetings to review contract performance and identify opportunities for improvement
- Analyzes customer needs and strategic direction, collects intelligence on competition, and determines opportunities to improve contract profitability and strengthen Apria’s strategic position
- Manages the contracting process including contract amendments, rate negotiation, rate approvals, language review, execution, and implementation of executed agreements both with the customer and internally
9
Responsibilities For Regional Director, Managed Care Contracting Resume
- Coordinates with Apria’s sales management to capture referral-source level revenue growth and product mix optimization opportunities
- Oversees daily operations of accounts and resolves identified service issues
- Maintains understanding of authorization process, DSO and account trends to ensure continuous improvement within each account, as well as coordination with operations management as needed
- Executes company initiatives, such as price improvement initiatives, program implementation, and new product rollouts
- Monitors revenue and profitability trends and key account performance indicators to ensure results are being achieved. Completes reports on contract opportunities and progress in achieving assigned objectives. Maintains database of account contacts and key account information
- Maintains database of account contacts and key account information
10
Responsibilities For Director Managed Care Va Resume
- Work with health plans to improve coverage positions for tests
- Reviews and respond to proposals and contracts
- Review managed care contracts from a financial and operational basis and work with business development, finance, and contract administrators in order to represent all interests in contract negotiations
- Communicates to the division and management on the performance of managed care customers, including problems, concerns, and issues related to billing/customer service and reimbursement
- Work with appropriate departments and managers to resolve issues
- Analyze and monitors fees for managed care customers
- Utilization review and analysis for capitation rate adjustments for capitated plans
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