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Director, Payor Contract Services

  • Job ID: 090497952
  • Status: Full-Time
  • Regular/Temporary: Regular
  • Hours:
  • Shift: Day Job
  • Facility: UPMC Pinnacle
  • Department: Managed Care Contracting
  • Location: 1426 N Third Street, Harrisburg PA 17102
  • Union Position: No
  • Salary Range: $51.57 to $77.34 / hour

Description

Purpose:
Integral member of the UPMC Payor Contract Services Team under the direct guidance of Vice President of Payor Contract Services, the Director is primarily responsible for the direct oversight of the day-to-day operations of the Payor Contract Services Department, supporting the contracting needs for UPMC Hospitals, Physicians and Ancillary services. Assumes a high impact role within UPMC and is a key contributor to the successful development and execution of contracts for all UPMC hospitals, physicians and ancillary providers. Optimizes interactions with providers and internal business partners to establish productive, professional relationships. The Director, Payor Contract Services will assist with achieving appropriate reimbursement for new emerging clinical protocols, framing new business opportunities and optimizing revenue through strategic negotiations. The Director will interact with UPMC executives and management, payor executives, associated legal representatives and payor contract services team to foster successful outcomes.

Responsibilities:

 

  • Develop staff ability to create associated spreadsheets and determine alternative approaches and methods to achieve contractual agreement to insure staff is well versed in all provider types and reimbursement methods to research and determine issues in the claim processing system.
  • Work in conjunction with legal department on contractual agreements, language revisions, and red-line document review. Work with additional internal departments including credentialing, medical management, revenue cycle and financial executives to proactively insure that potential contractual exceptions are functional and disseminated to the appropriate internal departments effected upon implementation.
  • Ensure that all policies, procedures, job descriptions, reports and other documentation are properly followed.
  • Ensure staff capabilities of verifying changes to contractual fee schedules, and enhancing their knowledge and use of ICD-10 diagnosis codes, CPT and HCPCS codes, MS-DRGs, AP-DRG, RUGs, APCs, CMGs, and all other reimbursement methodologies and provider types including hospitals, physicians, anesthesiology, skilled nursing facilities, acute rehabilitative facilities, home health agencies, hospice services, renal dialysis facilities, ambulatory surgery centers, behavioral health, transplant and their unique reimbursement calculations.
  • Manage day-to-day routine and non-routine departmental contracting and reimbursement activities, including project assignment and review. Develop project and summary prototypes that are consistently used and followed.
  • Collaborates cross-functionally to ensure resolution of escalated issues or projects.
  • Seeks new opportunities for enhancing UPMC Market Share or reimbursement through payor agreements or relationships. Develop policies and procedures, job descriptions, reports and other documentation related to departmental processes as appropriate.
  • Primary source of contractual negotiations and training of staff related to summarization of proposals and feasibility of reimbursement methodologies associated with new agreements. Achieve knowledge of geographic market variances and associated reimbursement methods and contracting to insure expansion efforts are completed timely and in accordance with expansion goals.
  • Implement, perform and manage financial analysis of new services, new programs and special projects as they arise.
  • Maintains and improves operations by monitoring systems and staffing performance. Identifies and resolves problems in collaborations with various departments across the UPMC enterprise.
  • Ensure staff capability of the review and red-line to contract proposals.
  • Research, evaluate, and summarize impact of regulatory changes or implementation of new rates or methodology as directed by Senior Management. Interpret and communicate results to all professional levels and departments within UPMC.
  • Ensures that staff delivers timely and accurate assignments. Completes administrative sign-off of all necessary human resources documentation, adhering to all human resources expectations for staff, with escalation to Vice President as needed.
  • Evaluate and develop action plan to address and resolve payment eroding patterns and findings.

 

Qualifications

  • Bachelor's degree in Business Administration, Accounting, Health Care Management, Information Systems, or a quantitative field of study (i.e. mathematics, economics, sciences, finance, etc.) with a minimum of 15 years relevant experience.
  • Master Degree in Business Administration, Health Care Management, Information Systems or a quantitative field of study (i.e. mathematics, economics, sciences, finance, etc.) with 10 years relevant experience will be considered.
  • Ability to prioritize and manage multiple simultaneous projects of varying size and complexity


Licensure, Certifications, and Clearances:
Clearances must be dated within 90 days
 

  • Act 33 with renewal
  • Act 34 with renewal
  • Act 73 FBI Clearance with renewal

UPMC is an Equal Opportunity Employer/Disability/Veteran

 

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   Current UPMC employees must apply in HR Direct