Job Details: Director, Managed Care

Description: Wake Forest University Physicians - Contracting
Wake Forest University Health Sciences
Wake Forest University Health Sciences (WFUHS), an institution encompassing the Wake Forest University School of Medicine (WFUSM) and its academic and research missions, is offering a newly created position of Director, Managed Care. WFUHS, along with North Carolina Baptist Hospital and Wake Forest University Physicians (WFUP), form the Wake Forest University Baptist Medical Center (WFUBMC), which is a leading academic medical center and top-ranked teaching hospital. WFUBMC is located in Winston-Salem, in the Piedmont Triad region of North Carolina.

The Director, Managed Care is responsible for leading WFUP's third-party payer contracting processes. The selected candidate will also serve at WFUP's lead negotiator with managed care companies and will be responsible for all reporting required to appropriately manage WFUP's contracting processes.

Characteristic Duties include:
Oversees financial analysis and direction of proposed and current commercial and governmental payer arrangements. Develops and operates appropriate models for gauging impact of proposed payer fee schedules on WFUP. Directs monthly reporting by department and/or specialty on reimbursement on a monthly, year to date and year end basis, and well as trending reports.

Provides leadership to departments to identify and research payment issues which may need to be addressed contractually. Provides leadership in working with external benchmark agencies to gauge WFUP's current and expected payment rates against local, regional and national payer rate benchmarks. Monitors, instructs and advises staff on payer contract changes in policies, procedures or processes.

Works with WFUP denials management and underpayment staffs to identify and resolve issues and identify issues which may need to be addressed contractually. Directs the appropriate ITS solutions to resolve and prevent future payment denials. Collaborates with NCBH Managed Care department to ensure integrity in WFUBMC's contracting and revenue cycle processes. Represents and participates in appropriate managed care or payer issue committees. Reviews, and adequately distributes provider manual information to the appropriate parties using multiple media platforms.

Maintains matrix of physician reimbursement specifics by payer, including modifiers, multiple surgery guidelines, silent PPO management and fee schedule analysis and maintenance. Aggressively tracks, uncovers and establishes processes to minimize effect of silent PPO actions. Serves as primary lead for WFUP's contract negotiation processes. Leads WFUP's provider credentialing activities.

Minimum Qualifications:
Requires a Bachelor's degree in Health Administration, Business Administration or related discipline and a minimum seven (7) years progressively responsible healthcare managed care, reimbursement or provider relations experience, preferably in an academic medical center or large tertiary teaching hospital or in the provider relations area of a managed care company.

Requires a strong knowledge of managed care contracts and reimbursement issues. Must possess strong database and spreadsheet development; analytical; presentation and communications skills, and work well in a team environment requiring a high degree of creativity and motivation.
Apply on-line with resume at http://www1.wfubmc.edu/wfuhs_hr Job ID # 11462. AA/EOE

Posting Date: Apr 29 08