Provider Payment Strategy Manager (Defined Term)

Central California Alliance for Health

14h•Hybrid

About The Position

We have an opportunity to join the Alliance as the Provider Payment Strategy Manager in the Payment Strategy Department. This is a Defined Term position, which is designated by the Alliance and is a position of limited duration. Defined Term employees are usually hired to work in a specific department on specific long-term project work until the work is completed or to a specific end date not to exceed December 31, 2026. This is a Defined Term and fully benefited position. Reporting to the Provider Payment Strategy Director, this position: Manages the advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including value-based payment, and advises executive leadership regarding the feasibility of various strategies and methodologies Utilizes a variety of methods and models to evaluate the feasibility of reimbursement methodologies Provides management oversight and guidance related to the provider reimbursement function, acts as a subject matter expert, and provides guidance on departmental operations Manages, supervises, mentors and trains assigned staff The Payment Strategy department ensures the Alliance's payments to our network are adequate to our revenue. We also work to advance our payment methodology in order to achieve the best quality healthcare while reducing costs. An experienced analytical and collaborative leader, with direct experience in managing provider payment strategies within a managed care setting Technically strong, with skill in provider reimbursement modeling, payment structure design and reimbursement strategies Strength in leading and mentoring teams while fostering ownership and accountability A collaborative and professional communication style, building productive relationships with internal teams and provider communities

Requirements

Principles and practices of provider reimbursement methodologies, pricing, and fee schedules for all provider types, including hospital, physician, and ancillary providers
Provider contracting, including language, reimbursement methods, and rates
Healthcare industry specific terms and healthcare related data types and structures, including member, claims, clinical and provider data
Data modeling techniques and business analytical and data mining tools, including SQL, and data visualization tools
Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS), ICD 9/10 and CPT codes, and industry standard groupers, such as ETGs, DRGs, and DCGs
Managed care concepts, contracting, policies, and procedures
Develop work plans and workflows and organize and prioritize provider reimbursement activities
Train, mentor, supervise, and evaluate the work of staff, promote an atmosphere of teamwork and cooperation, and motivate staff to achieve goals and objectives
Apply analytical and pricing expertise to the evaluation, negotiation, implementation, and maintenance of managed care contracts
Perform technical and non-technical troubleshooting and diagnose and resolve complex problems, including problems that may have multiple variables and may not have obvious solutions
Develop data-driven and outcome-based initiatives to improve business decision making and improve business processes
Bachelor’s degree in Finance, Economics, Accounting, Health Care or a related field
A minimum of eight years of experience performing provider reimbursement activities and/or provider payment strategy activities, including a minimum of three years of experience in a managed care environment, and a minimum of three years of management, supervisory, or lead experience; (a Master’s degree may substitute for two years of the required experience); or an equivalent combination of education and experience may be qualifying

Nice To Haves

An experienced analytical and collaborative leader, with direct experience in managing provider payment strategies within a managed care setting
Technically strong, with skill in provider reimbursement modeling, payment structure design and reimbursement strategies
Strength in leading and mentoring teams while fostering ownership and accountability
A collaborative and professional communication style, building productive relationships with internal teams and provider communities

Responsibilities

Manages the advancement of provider reimbursement methodologies to align with organizational strategies and objectives, including value-based payment, and advises executive leadership regarding the feasibility of various strategies and methodologies
Utilizes a variety of methods and models to evaluate the feasibility of reimbursement methodologies
Provides management oversight and guidance related to the provider reimbursement function, acts as a subject matter expert, and provides guidance on departmental operations
Manages, supervises, mentors and trains assigned staff