Fallon Health Senior Contract Manager - Managed Care Exp Needed in Worcester, Massachusetts
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Responsible for the analysis, negotiation/renegotiation, implementation, readjustment, evaluation, and continuous improvement of all functions related to provider contracting. Manages all financial and operational issues related to contractual provider arrangements. Responds to both internal and external customers regarding provider contractual arrangements, both for contract implementation and ongoing operations. Works closely with all areas of Compliance to make certain that provider networks for government programs are compliant with all state and federal provider requirements for each specific government product.
Negotiates, develops and designs key contractual provider arrangements that are important to the continued financial success of Fallon Health, including language and pricing methodologies.
Evaluates contractual payment methodologies in order to determine financial risk to insurer and provider (per diem, capitation, discount from charge, DRG, case rate, bundled payments, pay for performance programs, etc.). Ensures the design, production, and distribution of site financial, utilization and member information; ensures the production and completeness of annual site settlement reports. Acts as the primary liaison between the Plan’s Finance department and individual sites for budget, financial reporting and settlement arrangements for all relevant products.
Performs quantitative analyses of various financial and clinical data in order to evaluate multiple contracting options. Reports performance of ongoing contractual arrangements to appropriate internal and external parties. Recommends and implements strategies to improve financial and/or Plan’s operational performance to both internal parties and to external provider entities.
Manages and develops complex financial risk models for those arrangements where provider groups are at financial risk.
Manages, coordinates and resolves operational issues related to specific areas of responsibility. Serves as contact person for internal departments (i.e. Claims, Finance, Care Management Services, Patient Relations, Marketing, Credentialing, Provider Relations, etc.).
Researches, analyzes and presents recommendations to Director, VP, and/or members of the Fallon Health Senior Management Team regarding contractual and financial decisions.
Manages provider correspondence relating to contracts and responds to requests from potential new providers for FCHP.
Maintains tracking system for new and revised agreements. Coordinates and communicates contractual information to appropriate departments within FCHP.
Maintains assigned provider network; physician, hospital, ancillary, and/or carve out vendor as assigned by Director or Manager.
Prepares, updates and maintains files and database for all assigned provider contracts.
Provides mentoring and consultation to more junior contract managers.
Serves as committee member in cross-functional teams as assigned by Director.
Assists as requested in Provider Relations activities including servicing, educating and distributing information to contracted providers.
Bachelor’s degree or equivalent experience required. Master’s degree in Business Administration, Healthcare Administration, or Public Health preferred
Five years’ experience in managed healthcare environment(s) with related work in provider contracting, healthcare finance, provider reporting/profiling, and/or provider relations.
Experience in provider contract negotiations, including FFS, capitation models, and pay for performance models is preferred.
Excellent analytical, strategic thinking and creative thinking skills are required.
Superior verbal and written skills, excellent computer skills (Word, Excel, and Access) are essential to this position
Valid Driver’s License and Clean Driving Record Required
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Posted Date 2 months ago (6/1/2021 2:20 PM)
Job ID 6352
# Positions 1
Category Network Development