Description At ScionHealth , we empower our caregivers to do what they do best. We value every voice by caring deeply for every patient and each other. We show courage by running toward the challenge and we lean into new ideas by embracing curiosity and question asking.
Together, we create our culture by living our values in our day-to-day interactions with our patients and teammates. Job Summary Responsible for promoting, maintaining and assisting in the building of managed care relationships which will increase referrals and build steerage opportunities. Helps to build relationships and educates managed care payors and their clinical decision makers on the value of Kindred Services.
Majority of work is outside the facility.
Leadership Leads the planning and creation of the managed care strategic, operational, and service design for the specific market area. Manages the design, implementation and maintenance of the managed care information system including Managed Care Data Bases, Educational Manuals, contract rate dissemination & education in concert with Sr. Director of Managed Care.
Provides for a written scope of services, departmental policies and procedures that guide and support the provision and integration of contracts. Monitors performance improvement activities to measure and assess the quality and appropriateness of services provided to commercial patients. Job Specific Develops all area managed care initiatives, goals and activities.
Develops community based managed care strategy leveraging existing Kindred contracts. Identify specific managed care outcomes, participate in joint marketing and program presentations and identify issues that may be contributing to the blocking of future managed care admissions. Develops and Presents Continuing Education Programs (CEU's) to Referral Sources, Hospitals, MCO's and employees of Kindred.
Manages local conferences and meetings to educate MCO's to the programs, services and outcomes of Kindred Facilities. Communicates & prepares reports on activity, changes in industry, new business opportunities, statistical information/ market share & other as required by the facility's leadership team, and Sr. Director of Managed Care.
Implements weekly and monthly documentation indicating goals, activity and accomplishments to Sr. Director of Managed Care, CEO's/ Executive Directors in market area. Manages all activity surrounding commercial payors including: key decision-makers in the community including contracted and non-contracted medical groups, workers compensation organizations, health plans and hospitals.
Maintain close involvement/membership with State Self-Insured Employer Associations, Hospital Associations, Case Management Society of America (CMSA) Local/State Chapters and other. Responsible for creating a process for managed care Letters of Agreement and Out of Network admissions to facilitate appropriate admissions in accordance with the quality patient care objectives of the institution and established goals concerning patient census and financial feasibility.
Acts as liaison with managed care plan provider relations on claims-related problems and as intermediary when needed in resolving issues between internal departments or physicians and managed care plans. Address and resolve Utilization Management issues with managed care contractors Facility Case Management & Utilization Management staff and Clinical Case Managers Manages all contacts to managed care plan representatives.
Conducts inservices, education and training relating to the Kindred Continuum of Care. Identifies needs, develops programs in response to those needs in collaboration with the CEO's, Case Managers. Maintains good rapport and cooperative working relationships with clients.
Represent the organization in a positive professional manner in the community. Participates in Joint Operating Committee meetings within the Market. Works collaboratively with Director of Managed Care Contracting on development initiatives and implementation.
Company Specific Adheres to dress code, appearance is neat and clean and wears appropriate identification while on duty. Completes annual health, safety, and education requirements. Maintains professional growth and development.
Maintains confidentiality of all patient and/or employee information to assure patient and/or employee rights are protected. Demonstrates knowledge of the principles of growth and development over the life span and the skills necessary to provide age appropriate care to the patient population served. Reports to work on time as scheduled; adheres to policies regarding notification of absence.
Attends all mandatory in-services and staff meetings. Represents the organization in a positive and professional manner. Complies with all organizational policies regarding ethical business practices.
Communicates the mission, ethics, and goals of the hospital, as well as the focus statement of the department. Maintains current licensure/certification for position, if applicable. Consistently demonstrates Guest Relation's skills to patients, physicians, visitors, employees, and any other individuals with whom they may come in contact.
Consistently follows departmental and hospital Health, Safety, Security, Hazardous Materials policies and procedures. Knowledge/Skills/Abilities/Expectations Self-motivated and results oriented. Ability to apply knowledge of medical terminology and payor reimbursement methodologies including managed care requirements and strategies.
Strong organizational, interpersonal and communication skills. Ability to communicate in English effectively through verbal and written means. Ability to work under stress and deadlines.
Computer Skills Ability to Review and understand contract language. Ability to make presentations. Ability to travel frequently.
Qualifications Education Bachelors degree in business or related field, Nursing Masters degree preferred. Licenses/Certifications C. C.
M./ Certified Case Manager through The Commission for Case Manager Certification, Preferred. Experience Minimum of Five years healthcare experience. Three years experience in healthcare managed care business development required.
Knowledge of the Post-Acute Industry preferred.