Managed Care Program Manager

J  o  b    D  e  s  c  r  i  p  t  i  o  n

JOB INFORMATION

Effective Date:

Entity:

Wisconsin

Job Code:

312002

Job Title:

Managed Care Program Manager

FLSA Exemption Status:

Exempt

Management Level:

Supervisor/Program Manager

JOB SUMMARY

The Managed Care Program Manager is responsible for the development and maintenance of health plan and payer relationships. This position leads negotiations with managed care companies and health plans for agreements on behalf of the entire UW Health system, including UW Health-Northern Illinois, UnityPoint Health – Meriter, UW Rehabilitation Hospital and other entities. There are currently 15 entities to consider for each agreement. Depending on the entity, the Program Manager interacts with Directors, VPs and CEOs to ensure that agreements meet the entity's strategic goals in terms of revenue, market position and operations. These entities include: UWHC, UWMF, UWH – Northern Illinois, Madison Surgery Center, Transformations Surgery Center, Generations Fertility Care, Wisconsin Sleep, Chartwell, UW Rehabilitation Hospital, UnityPoint Health-Meriter and any new joint ventures in these negotiations and in these relationships. The Program Manager is responsible for ensuring the achievement of contract terms and conditions which are favorable to these entities. 

This position develops strategic planning for the entities and the payer relationships to achieve the financial goals of the organization. The Program Manager plans for negotiations to achieve financial targets, cover our market regions, maintain strong language terms and improve operational issues. This planning includes development of overall language, operational and financial improvements as well as careful evaluation of contracts open for negotiation, including identification of risks. These planning efforts represent about 30% of the Program Manager's time. The financial terms of these agreements drive the financial performance of the organization. These agreements represent 75% of the revenues for UWHC and UWMF. Payer relations throughout the year are managed carefully to achieve specific goals.

This position manages, maintains and develops relationships with strategically important third-party payers requiring significant experience in the field, as well as knowledge of the industry and provider systems. The Program Manager leads negotiations with executives at the health plan or payer. These negotiations may be contentious regarding operational issues, language complexities or rates, and the Program Manager role is to maintain a personal relationship while advocating strongly for the provider systems. In the rapidly changing health care environment, the Program Manager is in frequent discussions with the payer representatives throughout the term of the agreements, not solely during negotiations. With well over 100 contracts and individual rates for the various provider entities, these agreements are complex and require great attention to detail.

The Program Manager coordinates with all the various provider operational departments, business offices and Revenue Cycle departments to ensure that operational matters relating to revenue cycle management are incorporated into contracts. The incumbent works with medical school departments and hospital departments to develop payer and health plan strategy and to troubleshoot issues.  This position also communicates internally within UW Health and will develop effective presentations or memorandums to present to a wide audience of leaders and staff, within UWHC, UWMF, the Medical School or the other represented entities. 

ESSENTIAL DUTIES

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Interprets impact of broad scope organizational change for Managed Care and legal agreements. Develops change strategies for successful implementation.

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Incorporates UW Health’s vision, mission and values in goals for negotiations within Managed Care

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Formulates objectives, goals and strategies collaboratively with other stakeholders throughout the enterprise and with Joint Venture affiliates for financial, operational and clinical goals.

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Prepares and delivers reports to leadership at UW, UPH-Meriter and affiliates outlining progress towards meeting goals and objectives, including financial performance.

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Develops future short- and long-term plans for each system and affiliate payer relations, including plans for operational improvements to reduce administrative burden of payer requirements and plans for financial performance of individual contracts and the overall contract portfolio, considering the overall payer mix for each entity. This planning involves work with analysts, coordination with financial leaders of the provider entities as well as revenue cycle leadership.

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Responsible for the direct negotiation of a large portion of UW Health managed care contracts to achieve strategic contracting goals with a variety of health plans, payers and products.

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Respond to market opportunities and monitor significant market changes to protect and enhance market share for UW Health

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Meet with health plans for negotiation of rates and language, including development of agendas, preparation for negotiations and generally lead the meeting and negotiate key topics

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Develop contract language to achieve UW Health results, update, review and revise contract templates, revise health plan language to maintain compliance with State and Federal laws and specific provider entities’ requirements

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Ensure language meets the operational and financial needs of UW Health and other provider entities

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Evaluate financial performance and review trends for specific payers and comparison payers (within same portfolio), plan to meet financial targets, understand various provider reimbursement methodologies (hospital, physician, surgery center) and stay abreast of changing payment models

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Represent UW Health and the various entities in negotiations

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Manage the annual contract renegotiations ensuring that priority contracts are renewed prior to the termination date.

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Quote and advise on UW Health contract rates and negotiates rates as described by the Managed Care partner on the specific contract. Work directly with CFOs and other managers from provider entities on financial goals for the specific contract.

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Ensure client satisfaction through professional interactions on the phone, via email or mail and in person, building a relationship with the counterpart at the payer/plan, along with other directors and leaders in the payer/plan organization.

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Conduct orientations to UW Health for the payer/plan.

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Attend conferences with payer representatives, including representing UW Health at conferences, as a sponsor or contributor. Makes site visits and/or travels to payer/plan location as needed.

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Stay abreast of changes in the insurance or payer market.

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Organize meetings with payers, organize educational sessions, engage physician leaders as needed, coordinate and assist with case manager conferences.

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Address operational issues (clinical or business office) and facilitate solutions between the parties (can be patterns of issues or specific claims or urgent patient needs).

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Ensure contract language and final documents incorporate important revenue cycle management terms and conditions.

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Develop systems for communication on important contract terms, payer newsletters and any significant changes

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Manage communication to these departments and remove barriers for operations or communications, which include Provider Enrollment, Patient Resources, Prior Auth and the Access Center, Pharmacy, Rehabilitation Medicine, Revenue Cycle, Clinic Operations, etc. Escalate issues to leaders as needed.

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Establish and maintain effective working relationships with physician leaders, physicians, department administrators, Service line managers, senior leaders at UW Health and other provider entities’ management staff.

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Communicate pertinent contract information to all provider entities

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Facilitate operations meetings between internal provider departments and payers

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Troubleshoot and engage with specific departments or clinics as needed

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Oversee maintenance of the contract database

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Develop contract language for templates and ensure language is in compliance with Federal and State laws and supports UW Health’s requirements, as well as SAHS, UPH-Meriter and other entities.

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Review with Legal counsel

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Review with Revenue Cycle Teams

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Stay abreast of regulation and legal changes

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Manage the enrollment and credentialing process for UW Health.

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Complete delegated credentialing agreements, working with UW Medical Staff Affairs and other hospital’s credentialing managers .

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Coordinate with various Provider Enrollment departments for processes and policies with new and changing contracts

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Coordinate with various Marketing departments to ensure provider update processes are updated for new or changing contracts

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Coordinate and distribute certificates, licenses and other documents with all the provider entities to meet payer requirements.

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Serve as liaison to UW Health Strategy Office, including participation on committees, maintain relationship and provide communication to UHC leadership

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Coordinate and communicate with UWH-Northern Illinois, UnityPoint Health-Meriter, UW Rehabilitation Hospital, Chartwell Midwest Wisconsin and other relationships as assigned.

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Coordinate with other administrative and clinical department leaders within UW Health on contract issues and payer relations, including Quality and Safety Innovation, Population Health, Clinic Operations and Academic Departments.

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Serve as main point of contact for contract and payer relations for specific entities

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Serve on Managed Care Steering Committee, and other various committees.

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Prepare and deliver presentations as needed to various UW Health committees

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Remain current on the health insurance market, changes in legislation, contract compliance issues and the provider market.

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Provide back-up coverage for the other Contracting Specialists during their absences.

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Assist with budget process

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Other duties as assigned

As needed, additional responsibilities reasonably within the scope of duties and physical requirements may be assigned.  ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH PERFORMANCE STANDARDS AND RESPECT FOR PEOPLE COMMITTMENTS.

X

Non-Clinical

JOB REQUIREMENTS

Bachelor's Degree

. Four (4) years of experience may be considered in lieu of the degree in addition to the experience below.

Required

Master's Degree

Preferred

2 years

experience in healthcare organization or health insurance industry

Required

Experience in a large healthcare organization or academic medical center

Preferred

Professional or leadership/Negotiator roles in insurance and/or payer organization

Preferred

LICENSE, CERTIFICATIONS, AND REGISTRATIONS MUST BE MAINTAINED PER UW HEALTH POLICY. 

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Advanced knowledge of computer systems and ability to effectively utilize software applications including spreadsheet, , word processing, calendar and email. Experience in a MS Windows PC environment is preferred.

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Proven track record in negotiations. Ability to achieve stretch goals in difficult circumstances.

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Professional demeanor and ability to handle challenging communications when necessary and communicate complex concepts (written and verbal).

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Excellent organizational, time management, and problem-solving skills.

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Attention to the language and rate details in contracts.

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Ability to meet deadlines while managing multiple tasks.

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Ability to track, edit and monitor complex contracts with multiple language changes and a series of addenda.

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Ability to work across organizations, develop relationships, promote teamwork and represent physicians and hospital interests

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Effective interpersonal relations skills promoting teamwork and collaborative alliances.

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Knowledge of health care, health plans, managed care insurance

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Knowledge of principles and techniques used in negotiation

PHYSICAL REQUIREMENTS/WORKING CONDITIONS

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Sedentary: Ability to lift up to 10 pounds maximum and occasionally lifting and/or carrying such articles as dockets, ledgers and small tools. Although a sedentary job is defined as one, which involves sitting, a certain amount of walking and standing is often necessary in carrying out job duties. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Up to 10#

Negligible

Negligible

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Light: Ability to lift up to 20 pounds maximum with frequent lifting and/or carrying of objects weighing up to 10 pounds. Even though the weight lifted may only be negligible amount, a job is in this category when it requires walking or standing to a significant degree.

up to 20#

Up to 10# or requires significant walking or standing or requires pushing/pulling of arm/leg controls.

Negligible or constant push/pull of items of negligible weight

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Medium: Ability to lift up to 50 pounds maximum with frequent lifting and/or carrying objects weighing up to 25 pounds.

20-50#

10-25#

Negligible-10#

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Heavy: Ability to lift up to 100 pounds maximum with frequent lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

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Very Heavy: Ability to lift over 100 pounds with frequent lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide occupational qualifications not indicated above:

Over 50 lbs.

UW Health does not require, nor does it expect that its employees lift more than 50 lbs unassisted. Objects in excess of 50 lbs should be lifted or moved with mechanical means or through a team lift. Employees in patient care areas are expected to utilize mechanical lifts and adhere to the "Use of Mechanical Lifts (Liko)" policy in the Patient Services Policy and Procedure Manual.

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.

THE EMPLOYEE MUST BE ABLE TO COMPLETE ALL PHYSICAL REQUIREMENTS OF THE JOB WITH OR WITHOUT AN APPROVED ACCOMODATION. Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified; it is not intended to serve as an inclusive list of all responsibilities associated with this position.