Senior Director, Provider Reimbursement Programs

United States

Job Description

Responsible for developing and implementing provider reimbursement models (fee-for-service and value-based programs) that deliver industry leading cost, quality and clinical outcomes in accordance with Center for Medicare and Medicaid Services (CMS) and customer requirements.
  • Develops, implements and manages Magellan’s Behavioral Health provider network cost of care initiatives based upon internal and industry trends.
  • Partners with the provider network leadership, clinical and quality leaders to develop market specific strategies to achieve program objectives.
  • Establishes performance criteria for Value Based Program (VBP) vendors.
  • Based upon data analytics, provider networks and state/federal model specific requirements, develops an organization wide value-based incentive program for providers and members, to include selecting specific program parameters and/or measures for the program based on the product, developing a methodology and process for measuring and reporting on progress to providers and market leaders, developing a contracting strategy and amendment for use by network teams, developing and supporting vendor implementation of provider scorecards, and optimizing data collection.
  • Develops all documentation, operational workflows and work products necessary and required to ensure the ongoing operation of the provider reimbursement methodology and value-based program (VBP), ensuring successful accountability and reporting for downstream work activity required to execute the objectives.
  • Develops solutions in partnership with clinical, provider network, and quality resources on how to educate providers on VBP.
  • Establishes governance process for reporting progress and course correcting local and national resources to achieve objectives.
  • Monitors changes in federal and state laws and regulations that impacts programs designed by the Center for Medicare and Medicaid Services (CMS), state programs designed to place payment for services in risk contracting relationships with providers, and various relationships with health care payers and governments.
  • Monitors CMS and industry reimbursement methodologies to propose and implement provider reimbursement schemes.  This will include professional and facility reimbursements.

General Job Information

Title

Senior Director, Provider Reimbursement Programs

Grade

30

Job Family

Operations Group

Country

United States of America

FLSA Status

United States of America (Exempt)

Recruiting Start Date

2/24/2020

Date Requisition Created

2/24/2020

Work Experience

Contract Administration and Management, Healthcare, Management/Leadership

Education

Bachelors (Required), Masters: Business Administration

License and Certifications - Required

License and Certifications - Preferred

Other Job Requirements

Responsibilities

  • Bachelor’s degree in healthcare, healthcare policy, public health, finance, or related field.
  • 10+ years of experience in managed care, payer/provider/health plan or health system management.
  • 10+ years contract administration and management.
  • 7+ years of experience leading high-performing teams and fostering relationships in a matrixed environment.
  • Must have experience successfully negotiating value-based contracts with providers.

Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.