Establish and maintain relationships with managed care referral sources, including local, regional and national payors, re-insurers, and national Center of Excellence (COE) networks. Serve as main resource regarding Managed Care market trends.
* Maintain payor/national COE network profile information.
* Collaborate with Strategy & Business Development and Marketing Departments to assess payor market share and project potential volume from COE networks.
* Facilitate submission of national COE quality surveys -which support UMMC Strategy & Business Development and Marketing initiatives.
* Maintain Payer Relations and acts as System resource for COE contracting.
2. Market program, services and key physicians directly to payors/national COE networks.
* Introduce key faculty/programs and physician/hospital leadership to payor/national COE Medical Directors and payer staff.
* Promote University of Maryland Faculty Physicians (FPI) and UMMC programs to payers and national Center of Excellence networks.
* Facilitates & hosts site visits by national COE network leaders.
3. Negotiate/re-negotiate specialized contracts, including professional and facility services, to achieve optimum reimbursement and risk protection under fixed rate agreements. Primary contracting focus for both risk and/or non-risk, non-traditional contracts for Bariatric, Cardiac, - Transplant, Cancer Care, Neurocare, Orthopedics and other service lines that national COE networks require non-traditional contracting for inclusion in their programs.
* Develop and negotiate scopes of service to limit financial risk and to facilitate contract operational performance.
* Identify and negotiate risk corridors, exclusions, bill aboves, and other contracting strategies to minimize financial risk; will require significant interaction with clinical faculty and staff associated with clinical services.
* Conducts pricing and ongoing analysis of financial reimbursement performance of assigned service line agreements.
* Negotiate optimal reimbursement for Physician practices and UMMC.
* Collaborate with Director of - Payer Relations & Contracting, - FPI, and Physician/Hospital leadership to finalize contract language and payment rates. In addition, prepare and submit alternative rate applications to -VP of Reimbursement & Revenue Advisory Services for approval by the Maryland Health Services Cost Review Commission.
* Support contract implementation, by developing contract-training materials and conducting training for operational performance.
4. Improve contract performance
* Work with hospital finance and physician/department leadership to improve contract performance measurement and revenue enhancement initiatives.
* Establish FY Global Budget based on anticipated contract volume and re-forecast Global Budget as required
* Improve actual/expected revenue on contracts by collaborating with executive and departmental leadership to address service line issues that impact national COE network participation and global revenue.
* Re-negotiate contracts to limit scope of service and maximize reimbursement for physician practices and UMMC.
* Manage specific payor/national COE network account.
5. In collaboration with UMMC/FPI's Office of the General Counsel, expedites settlements for outstanding global payment denials with payer/national COE network executive leadership. Negotiates Single Case Agreements with national networks for services which involve high-cost new technologies and for services which are out-of-network.
* Negotiate - single case agreement contracts to achieve optimal reimbursement and minimize financial/clinical risk.
* Collaborates with departmental physician leads to facilitate submission of COE determination appeals
* Create and implement revenue enhancement strategies.
6. Key liaison responsible for facilitating all Requests for Proposals (RFP) and/or Requests for Information (RFI) from Payors/national COE Networks.
* Assess financial and clinical opportunity/risk of RFI/RFP award.
* Evaluate payor's/national COE network's existing provider network and determine opportunity for revenue and volume.
* Collaborate with Strategy & Business Development and Marketing Departments to assess potential market share, volume and revenue.
* Collaborate with Department heads, physician leadership, clinical staff and other key personnel to facilitate data/information response
* Define product's competitive edge through RFP/RFI process.
* Leads the process from receipt of RFP/RFI through final contract negotiations.
* Responsible for informing/advising and obtaining buy-in of clinical leadership on market requirements for - COE status and approach or agreement on participation.
