Health Plan Administration is responsible for development of payor strategies, negotiation and management of payor contracts, reporting and monitoring of payor and contract performance and administering the St Charles Caregiver Health Plan (the Plan). The Plan includes medical, dental, vision, FSA and HSA benefits for St Charles caregivers, their spouses and dependents.
The Director of Payor Contracting and Health Plan provides strategic leadership and direction to guide and enhance the performance and financial position of St. Charles Health System. The primary responsibility of this position is to lead St. Charles Health System into successful value-based models for Medicaid, Medicare and Commercial health plans. This position participates in the development and negotiation of contract terms, and carries out policies and guidelines specific to Commercial, State and local government payor reimbursement contracts, employers and other third party payors, as well as development of payment methodologies related to existing and new models of care. Additionally, this position is responsible for the development and management of a coordinated systems-level health plan that improves the health of the caregivers and provides better value of healthcare costs. Accountable for the creation and management of the transition to value-based payment models and the health plan administration infrastructure, this position plays a key role in the development and implementation of long-term strategic goals for St. Charles. In serving in these capacities the position reports directly to the Senior Vice President/Chief Financial Officer and indirectly to the Senior Vice President/Population Health.
(May perform additional duties of similar complexity within SCHS as required or assigned)
Leads contracting strategy development and implementation to include negotiation of contract financial terms with payors, such as commercial plans, employer self-funded plans, government programs and fiscal intermediaries, and vendors, such as brokers, third party administrators, pharmacy benefit management firms, financial institutions and others.
Establish acceptable contract language and serve as St. Charles Health System contracting lead for care model redesign. Facilitates contract dispute resolution between St. Charles Health System operations and external entities.
Serves as a representative for various state and regional initiatives regarding payment reform, primary care access, and care model redesign. Develops partnerships with healthcare and community leaders to improve access to care for the insured and uninsured. Maintains working knowledge of applicable laws, regulations and legislative changes affecting reimbursement, insurance marketplace and health plan administration.
Provides strategic thinking and planning to identify the areas in which collaboration could provide optimal benefit and innovative opportunities for St. Charles and the Plan, working with caregivers, employer groups, state and government programs
Works with key senior management and others to implement and provide direction that relates to the service and financial success of the Health Plan Administration department. Collaborates, plans, coordinates, analyzes and implements strategic and tactical approaches to meet the clinical and financial expectations of St. Charles Health System.
Directly manage all aspects of the health plan administration department, to include financial oversight, sales/marketing, membership and enrollment, product development, provider network, provider relations, payor contracting and relations, provider and delegated credentialing, clinical utilization management and review, vendor contracts and relationships, data reporting and analysis, and day-to-day operations of the Plan.
Identifies new opportunities for health plan administration, through models of care redesign, new collaborations, partnerships and changes in health care reform with state and federal agencies, employers, health plans and others. Serves as project manager for financial and quality performance metrics for risk programs; oversight for successful completion of metrics to recoup withholds and surplus funds.
Contribute to other projects throughout the System that require multi-disciplinary approaches, serving as counsel and facilitator to build bridges with other departments and to achieve coordinated solutions in the ever-changing reimbursement environment. Serve on Compliance Work Group.
Provide analytical support in conjunction with Finance for the purpose of reviewing contract financial performance, specifically advising the executive team and individual managers concerning financial implications of existing or proposed activities related to development of contract strategy, negotiations, the Plan and the financial implications of contemplated business decisions.
The scope of responsibility includes the Plan and the entire St. Charles Health System’s system, its divisions, departments, and its four regional hospitals and employed physicians for contracting and payor relations.
Ensures the accomplishment of the organization’s mission, vision and values in the Triple Aim. Monitor performance indicators to support development and improvement of department. Responsible for budget development, regular monitoring, accountability and meeting all operational targets for all areas within span of control.
Coaches and mentors, staff across their area of responsibility to enhance skills, achieve high levels of performance, and create a culture of continuous learning that delivers on the mission. Hires, directs, coaches and monitors the performance of all direct reports, to develop and maintain a high performance team that meets organizational and department goals. Monitors and ensure all direct reports are current with compliance and safety requirements. Implements and manages all organizational safety directives and goals.
Provides and oversees team’s delivery of customer service in a manner that promotes goodwill, is timely, efficient and accurate. Provides and maintains a safe environment for caregivers, patients and guests.
Supports Value Improvement Practice (VIP- Lean) principles of continuous improvement with energy and enthusiasm, functioning as a champion of change.
Conducts all activities with the highest standards of professionalism and confidentiality. Complies with all applicable laws, regulations, policies and procedures, supporting the organization’s corporate integrity efforts by acting in an ethical and appropriate manner, reporting known or suspected violation of applicable rules, and cooperating fully with all organizational investigations and proceedings.
May perform additional duties of similar complexity within the organization, as required or assigned.
Required: Minimum of a Bachelor's degree in Business, Health Care Administration or in related field with comparable experience equating to same skill set.
Preferred: MBA, MPA, MS
Required: Valid Oregon driver’s license and ability to meet St. Charles Health System driving requirements
Ability to travel to business functions/trainings/meetings and all St. Charles Health System worksites
Required: A minimum of 7 years’ experience in healthcare management and Managed Care/Payor Contracting in a healthcare setting.
ADDITIONAL POSITION INFORMATION
Experience in new product development, organizational management, business communications, systems analysis, accounting/fiscal systems and reimbursement, office and personnel management. Proven experience in building and leading teams, effectively managing change, solid business acumen leveraging resources, with demonstrated visionary skills. Skilled in handling potentially adversarial situations requiring resolution; ability to build and maintain a high level of trust and consensus over complex issues. Understanding the dynamics of change management and sensitivity to an industry and organization undergoing significant changes.