As a service line of TPIRC, the Southern California Food Allergy Institute treats over 10,000 food allergic children at its Long Beach, CA location. The Southern California Food Allergy Institute deploys artificial intelligence, machine learning and uniquely comprehensive diagnostic testing to design individualized data based therapeutic treatment plans for food allergy patients. The result of this diagnostic and treatment process is remission from food anaphylaxis. The institute requires the expertise of a contracts and billing revenue director in order to maximize contracts and billing revenue across the diagnostic lab and clinical visits. Over 50% of our patients travel from across the United States for treatment. This role requires knowledge and expertise in contract affiliation and negotiation with the largest PPO organizations at the regional and national level. The goal of the organization is to receive specific contract opportunities at this geographic level to enhance the patient experience. The unique model of food anaphylaxis treatment offered at the Southern California Food Allergy Institute is limited to our center only. Hence, experience in contracting niche medical services is preferred.
The Director of Managed Care Contracting is responsible for the overall development and implementation of payer partnerships and payer network strategy for TPIRC and its subsidiaries. This position will establish TPIRC's managed care program by developing and analyzing payer contracting strategies, negotiating contracts with managed care companies and health plans, including HMOs, PPOs, and other products. Our Director will provide leadership to maintain effective payer partnerships through establishing and maintaining relationships with internal and external sources involved in the contracting process, developing contract language and negotiation strategy, and in-depth financial analyses of contract performance. This position reports to the Chief Executive Officer and will work closely with members of the executive team as needed.
- Responsible for direct negotiation of TPIRC’s managed care contracts to achieve strategic contracting goals
- Engage contacted network leaders and establish positive business relationships
- Develop contract structures that are appropriate to the company, including the full range of reimbursement structures and considering cost of care or performance targets
- Develop strategy for contract relationships, including specific products (for ex: HMO, PPO and other health plans)
- Analyze significant and unique contract requirements, special provisions, terms and conditions to ensure compliance with appropriate laws, regulations, and TPIRC policies and business procedures
- Source and qualify opportunities for TPIRC to enter contracts and partnerships with payers and monitor significant market changes to protect and enhance market share
- Develop strategies to address ongoing pressure for reimbursement levels and work collaboratively with payers on new payment models and business opportunities
- Analyze the significance and value of potential contracts; determine the cost of care based on care delivery and contract structure.
- Monitor contract performance and other provisions to ensure compliance, identify problem areas and resolve disputes
- Responsible for overseeing operations that develop and maintain positive relationships and financially viable contracts with payers and ongoing analysis of existing contracts for compliance and performance review as well as analysis for budgeting revenues, long-range planning
- Make recommendations as to the desirability of canceling, renegotiations or extending contracts
- Direct and support staff to achieve organizational goals by communicating job expectations, planning, monitoring and appraising job results, coaching and counseling, driving increased employee engagement.
- Produce operational statistical reports to provide contracting team with necessary tools for effective decision making and strategy including analysis, trending and comparative data (cancellation reports, identifying trends in no referral/authorization, timely filing, no provider certification, A/R aging, & etc.).
- Facilitate payer meetings, including preparing agendas, attending meetings, etc.
- Provide timely updates on renewals, amendments and other contract changes that need to be communicated
- Evaluate requirements for out of state plans, make recommendations and coordinate with the interpretation/feasibility of non-standard requirements
- Research and investigate related laws or regulations for contracts, health insurance, coverage and related topics
- Strong and direct payor negotiating experience required
- Effective communicator at all levels in the organization, with strong oral, written and persuasive skills
- Knowledge of and experience with CPT-4 and ICD-9 and HCPC billing, coding and posting charges in medical billing software
- Knowledge of insurance guidelines including HMO/PPO, Medicare, Medicaid, and other payer requirements and systems
- Knowledge of insurance plan benefits and terminology
- Knowledge of and experience with contract payer policies and procedures
- Strong written and verbal communication skills with and
- Highly proficient in Microsoft Excel, Word and Access including import/export functions
- Bachelor’s degree required, Masters degree in health care administration, business or related field preferred
- Minimum of five years in healthcare payor contracting and reimbursement, either on the payor side or within a hospital or diagnostic laboratory setting