This company is an equal opportunity employer and makes employment decisions without regard to race, color, sex, sexual orientation, gender identity, national origin, disability or protected veteran status. This company is a VEVRAA Federal Contractor.

Position Goal: The Managed Care Director is responsible for all aspects of contract management including performing the review, modeling, negotiation, analysis, implementation, and maintenance of the group managed care contracts related to the Clinic, Surgery Center, and Hospital.
 

• Presents contract proposals and analysis and responds to requests for proposals from third party payors.
• Oversees managed care reimbursement ensuring payment compliance with all Commercial, BCBS, Medicare, Medicaid, Tricare, and Workers’ Compensation agreements.
• Fee schedules.
• Underpayment appeals.
• Develops, manages, and strengthens relationship with contracted payers.
• Provides results of Payor information gathered, trends, concepts, processes, and requirements to facilitate education, problem resolution and operational improvement to all appropriate managers and staff.
• Works with Credentialing to update group participating insurance/network lists.
• Assists CFO and Business Office Director with credentialing staff providing oversight, direction, and leadership to the team.
• Provider facility privileges for initial appointment and re-appointment(s).
• Provider managed care credentialing and re-credentialing.
• Provider enrollment (individual & group).
• Provider disclosure forms (individual & group).
• Provider data management.
• CAQH, NPPES, and Pecos enrollment/maintenance.
• Interacts frequently with internal departments and external vendors; particularly in problem resolution.
• Assist managers and clinic staff with various Payor prior authorization, complex posting, eligibility, protocol, referrals, enrollment, and billing issues that relate to contracting.