Managed Care Contracting, Performance Advisor

This is a fully remote position, open to applicants in United States.

📋 Description

• Strategically oversee, assess, negotiate, implement, and monitor managed care contracts.

• Review and audit current contracts to uncover reimbursement enhancement, optimization, and renegotiation opportunities.

• Conduct financial modeling and reimbursement analysis for rate adjustments, amendments, and new payer arrangements.

• Assess contract language, reimbursement methodologies, payment policies, authorization requirements, carve-outs, and contractual commitments.

• Create business cases and executive-level recommendations for strategic contract decisions.

• Design and execute negotiation strategies for commercial, Medicare Advantage, Managed Medicaid, and other payers.

• Analyze payer proposals and formulate data-driven counterproposals.

• Maintain communication and relationships with payers to address negotiation challenges and facilitate contract execution.

• Coordinate the implementation of new or revised managed care agreements.

• Collaborate with Finance, Revenue Cycle, Patient Access, Case Management, Physician Services, Operations, and payer organizations.

• Develop contract summaries, reimbursement guides, and operational reference materials.

• Support payer configuration, billing implementation, reimbursement validation, and operational training.

• Address contract interpretation and post-implementation challenges.

• Establish and track KPIs for reimbursement accuracy, denial trends, payment timeliness, underpayments, and revenue yield.

• Investigate, escalate, and assist in resolving underpayment, denial, and reimbursement conflicts.

• Analyze payer performance and identify opportunities for revenue recovery and compliance improvements.

• Prepare executive reports and presentations on contract performance, negotiation status, financial implications, and recommendations.

• Identify and evaluate new payer, IPA, medical group, and physician contracting opportunities.

• Assist in strategies for physician network and medical group contracting.

• Support initiatives related to value-based care, risk-based contracting, and alternative payment models.

• Contribute to managed care strategies that promote organizational growth, financial viability, and market expansion.

⛳️ Requirements

• Bachelor’s degree with a minimum of 6-8+ years of relevant experience, or an AA degree with 8-10+ years of relevant experience.

• Relevant experience may substitute for formal education or advanced degrees.

• Relevant experience in a healthcare provider setting, central business office environment, managed care, contracting, healthcare finance, payer relations, related healthcare administrative roles, or revenue cycle outsourcing company.

• Proven experience in negotiating managed care agreements with commercial and government-sponsored health plans.

• Experience in conducting reimbursement analyses, financial modeling, and contract evaluations.

• Knowledge of hospital and physician reimbursement methodologies, including Medicare, Medicaid/Medi-Cal, DRG, APC, fee schedules, capitation, and value-based payment models.

• Strong grasp of managed care contract language and reimbursement structures.

• Advanced analytical and financial modeling capabilities.

• Ability to interpret complex contractual and reimbursement provisions.

• Strong negotiation, communication, and relationship management skills.

• Capability to work effectively across multiple departments and levels within the organization.

• Excellent project management and organizational abilities.

• Proficient in Microsoft Excel, PowerPoint, and healthcare financial analytics tools.

• Willingness to travel up to 10%.

• No clearance required.

🏝️ Benefits

• Competitive compensation.

• Flexible benefits package.

• Medical, Rx, Dental & Vision Insurance.

• Personal and Family Sick Time & Company Paid Holidays.

• Position may qualify for a discretionary variable incentive bonus.

• Parental Leave.

• 401(k) Retirement Plan.

• Basic Life & Supplemental Life Insurance.

• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts.

• Short-Term & Long-Term Disability.

• Tuition Reimbursement, Personal Development & Learning Opportunities.

• Skills Development & Certifications.

• Employee Referral Program.

• Corporate Sponsored Events & Community Outreach.

• Emergency Back-Up Childcare Program.