General Summary

Under the supervision of the Director of Payer Relations & Contracting, serves as key liaison to UMMC and FPI leadership as well as physician, clinical and administrative staff for physician and hospital specialized, high-cost service contracting. Acting as the primary contact with payor organizations and national Center of Excellence networks, utilizes revenue protection strategies to assess contracting opportunities, conducts contract negotiations/re-negotiations, and manages contract/payor relationships to improve actual/expected revenues and maximize volume. In addition, this position may work with a service line product management to discuss challenges with transplant programs so that comprehensive marketing programs may be developed to assist with increasing volume for selected specialized programs. Conducts market research as necessary, and engages and secures buy-in of UMMC, FPI and physician leadership, clinical and administrative staff for awareness and compliance with appropriate market quality and patient safety initiatives. Utilizes appropriate marketing, sales and outreach tools to raise awareness, emphasize the strengths and competencies, and encourage consumers, physicians and insurers to use specialized tertiary services at UMMC.

Principal Responsibilities and Tasks

The following statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by personnel so classified.

1. 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.