Houston Methodist
Overview
At Houston Methodist, the Director Managed Care Contracting position is responsible for the development, negotiation, maintenance and payer relations of the Houston Methodist (HM) contracts for reimbursement of services billed through managed care companies and serves as a technical expert for management and operations staff of specific HM facility and Physician Organization contracts for reimbursement of services billed through managed care. The managed care payers include commercial payers, separate transplant contracts, Medicare Advantage, Medicaid Health Maintenance Organizations (HMOs), International, behavioral health, workers' compensation, student insurance, bundled payment contracts, quality metric bonus program and risk contracts. The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations. People Essential Functions
Directs, develops and implements strategic and operational/high level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives. Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees. Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators. Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Identifies opportunities and takes action to build strategic relationships between one\'s area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed. Develops and maintains ongoing relationships with payers, physicians, and hospital staff. Service Essential Functions
Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department. Provides assistance to finance, accounting, operations teams regarding interpretation of contracts and applied billing. Utilizes a thorough understanding of managed care operations to maximize reimbursement. Quality/Safety Essential Functions
Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/ licensing agency and/or department guidelines as applicable. Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety. Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). Analyzes contract proposals including but not limited to analysis of per diems, carve outs, new procedures, new drugs. Analyzes proposals which include capitation reimbursement, Medicare resource-based revenue value scale (RBRVS) values, current procedural terminology (CPT) coding, discounts, carve outs, new procedures, new drugs, diagnosis related groups (DRGs) ambulatory payment classifications (APC), etc. Directs the contracting process and all documentation related to contract pricing, rate structures, addendums, and language requirements. Analyzes and manages payer quality metric bonus and risk programs in conjunction with internal partners. Finance Essential Functions
Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost-effectiveness. Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. Pursues revenue enhancement opportunities through the contracting process both at the time of renewal, and through regular review of existing contract specifications. Oversees and manages new payer negotiations and renegotiations in conjunction with other Managed Care leaders and executives and system executive team and legal department. Growth/Innovation Essential Functions
Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/ system-directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings. Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate. Ensures own career discussions occur with appropriate management. Completes and updates My Development Plan (MDP) on an on-going basis. Conducts conversations with staff on their development and MDP. Actively participates and contributes to the managed care strategic planning process and decision making on traditional and innovative payment models and creating the optimal course that incorporates fee-for-service and value-based designs. Partners with hospital clinical performance executives in creating performance measurements for new care models to support meeting performance targets. This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. Education
Bachelor\'s degree in business administration, healthcare administration, finance, nursing or a related field required Master\'s or Juris Doctor (JD) degree preferred Work Experience
Five years experience in a complex healthcare environment to include provider, payer, consulting, technology or related specialty and two years people management experience.
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At Houston Methodist, the Director Managed Care Contracting position is responsible for the development, negotiation, maintenance and payer relations of the Houston Methodist (HM) contracts for reimbursement of services billed through managed care companies and serves as a technical expert for management and operations staff of specific HM facility and Physician Organization contracts for reimbursement of services billed through managed care. The managed care payers include commercial payers, separate transplant contracts, Medicare Advantage, Medicaid Health Maintenance Organizations (HMOs), International, behavioral health, workers' compensation, student insurance, bundled payment contracts, quality metric bonus program and risk contracts. The Director position responsibilities include overseeing the activities of the department staff, ensuring quality, productivity, functional excellence and efficiency to accomplish strategic and operational objectives. In addition, this position is accountable for employee engagement, adequate staffing levels, budget development and compliance, staffing decisions such as hiring and terminating employment, coaching and counseling employees on work related performance, and developing and implementing policies and procedures to ensure a safe and effective work environment. This position also ensures training, monitoring and operations initiatives are implemented which secure compliance with ethical and legal business practices and accreditation/regulatory/government regulations. People Essential Functions
Directs, develops and implements strategic and operational/high level projects and processes either through independent/highly autonomous work or through the facilitation of work teams to enable the effective and efficient completion of objectives. Oversees management of and ensures development for staff to meet overall objectives in terms of quality, service and cost effectiveness. Provides timely guidance and feedback to help others strengthen specific knowledge/skill areas needed to accomplish a task or solve a problem. Directs management responsibilities of selection, scheduling, supervision, retention, and evaluation of employees. Meets or exceeds threshold goal for department turnover and/or system metrics on employee engagement indicators. Provides leadership and communication to maintain a competent and engaged employee group by conducting regular department meetings to review policies and procedures and operational matters, rounding on all employees, completing performance appraisals, conducting new hire feedback sessions, coaching/corrective counseling, and providing recognition/commendations to achieve desired outcomes. Identifies opportunities and takes action to build strategic relationships between one\'s area and other areas, teams, departments, and units to achieve business goals. Drives the promotion of teamwork within and between departments; participates and/or leads and facilitates department process improvements as needed. Develops and maintains ongoing relationships with payers, physicians, and hospital staff. Service Essential Functions
Oversees department operations, designated projects, schedules and activities as needed to ensure that goals or objectives are accomplished within the prescribed time frame. Sets priorities and functional standards, giving direction to staff as necessary to ensure the best possible delivery of service and high customer/patient satisfaction. Drives department service standards and activities to impact department and/or system score for patient/customer-based satisfaction, through role modeling and fostering accountability. Serves and actively participates on various entity committees as a voice for the department. Provides assistance to finance, accounting, operations teams regarding interpretation of contracts and applied billing. Utilizes a thorough understanding of managed care operations to maximize reimbursement. Quality/Safety Essential Functions
Ensures a safe and effective working environment; monitors and/or revises the department safety plan and/or any specific accreditation/regulatory required safety guidelines. Responsible for staff maintenance of credentials and competencies, per accrediting/ licensing agency and/or department guidelines as applicable. Employs a proactive approach in the optimization of safe outcomes and information systems by monitoring and improving the department workflow and enhancing operations, using peer-to-peer accountability and identifying solutions via collaboration. Implements process improvements utilizing tools such as lean principles. Role models situational awareness, using teachable moments to improve safety. Responsible for employee compliance to policies and procedures and performs associated actions upon non-compliance (i.e., licensure/certification compliance, focal point review requirements, disaster plan, in-services, influenza immunization, wage and hour, standard hours, timely termination submission, timely timecard approval, etc.). Analyzes contract proposals including but not limited to analysis of per diems, carve outs, new procedures, new drugs. Analyzes proposals which include capitation reimbursement, Medicare resource-based revenue value scale (RBRVS) values, current procedural terminology (CPT) coding, discounts, carve outs, new procedures, new drugs, diagnosis related groups (DRGs) ambulatory payment classifications (APC), etc. Directs the contracting process and all documentation related to contract pricing, rate structures, addendums, and language requirements. Analyzes and manages payer quality metric bonus and risk programs in conjunction with internal partners. Finance Essential Functions
Develops and manages department operational and capital budgets, approvals, and ongoing maintenance of the department(s), ensuring operation in a cost-effective manner. Proactively identifies and plans for capital needs related to current equipment and future department projects. Ensures staffing plans and schedules meet department needs that reflect understanding of the importance of cost-effectiveness. Creates department strategies to achieve financial target and staffing needs, through optimizing productivity, supply/resource efficiency, minimizing incidental overtime and overtime percentage, and other areas according to department specifications. Pursues revenue enhancement opportunities through the contracting process both at the time of renewal, and through regular review of existing contract specifications. Oversees and manages new payer negotiations and renegotiations in conjunction with other Managed Care leaders and executives and system executive team and legal department. Growth/Innovation Essential Functions
Identifies and implements innovative solutions for practice or workflow changes to improve department, entity or system operations by leading unit projects and/or other department/ system-directed activities. Proactively leads task forces and committees. May represent HM at assigned community or professional organization meetings. Drives change initiatives, maintaining effectiveness when experiencing major changes in work responsibilities or environment; adjusts effectively to work within new work structures, processes, requirements or cultures. Partners effectively with stakeholders as appropriate. Ensures own career discussions occur with appropriate management. Completes and updates My Development Plan (MDP) on an on-going basis. Conducts conversations with staff on their development and MDP. Actively participates and contributes to the managed care strategic planning process and decision making on traditional and innovative payment models and creating the optimal course that incorporates fee-for-service and value-based designs. Partners with hospital clinical performance executives in creating performance measurements for new care models to support meeting performance targets. This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises. Education
Bachelor\'s degree in business administration, healthcare administration, finance, nursing or a related field required Master\'s or Juris Doctor (JD) degree preferred Work Experience
Five years experience in a complex healthcare environment to include provider, payer, consulting, technology or related specialty and two years people management experience.
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