Program Director – Contract Performance - Medical Economics - Southwestern Health Resources (SWHR)

Here’s What You Need

Education

• Bachelor’s Degree in Business required.

Experience

• Require 5 years’ experience in Accountable Care Organizations or Health Care Related Services, managing the operational performance of Regulatory & Value-Based Contracts.
• Highly prefer 5 years of experience in Project Management.

Skills & Abilities

Work requires:

• Ability to exercise considerable judgment and great attention to detail.
• Ability to review, develop, recommend, and implement policies.
• Demonstrated database, analytical, and presentation skills.
• Excellent interpersonal, customer service, supervisory, organizational, time management and leadership skills.
• Ability to work independently, research and resolve questions and problems.
• Ability to understand regulatory language and requirements.
• Ability to understand contract risks and ability to mitigate.

What You Will Do

Position Responsibilities

The Program Director – Contract Performance will develop and direct the implementation of strategies and processes for effective filings, submissions, audits and compliance with regulatory laws and policies that govern the Value-Based Contracts.

Position Functions

• Directs and facilitates key cross functional teams to execute on the daily, quarterly, and annual value-based regulatory activities including operational reporting activities, strategic initiatives, financial reporting, and facilitate ongoing implementation of compliance requirements.
• Oversees and provides subject matter guidance to Physician recruitment and Physician development teams for the provider submission adds/terms on a monthly basis during the performance year to ensure regulatory rules and policies are adhered to including TIN/NPI restrictions, overlap rules, provider eligibility.
• Review and manage the provider enhancements add/terms on a monthly basis during the performance year to ensure regulatory rules and policies are adhered to including TIN/NPI restrictions, overlap rules, SNF eligibility provided by business owners.
• Directs other internal departments to facilitate and comply with regulatory process of all beneficiaries, providers, executive notifications monthly, quarterly, annually and working with operational teams such as call center, provider engagement teams, marketing, compliance, to ensure training/understanding/ownership is defined. Development of FAQs are implemented if needed, training, and audit/retention requirements of all notices.
• Supports and oversees from a contractual standpoint the implementation of all benefit enhancements and annual resubmission by submitting implementation plans to regulatory program timely. Work with operational teams and compliance to begin internal roll out of benefit or rollout training to new team members on revised/current process.
• Responsible to ensure appropriate teams sends out beneficiary's eligibility each month to business owners for benefit enhancements.
• Supports Program integrity by directing the process flow with compliance and business owners for beneficiary enhancement denials and supporting next steps to the MAC.
• Develops and manages process with market and compliance to update website and marketing materials on monthly basis.
• Facilitate all submission of audits done quarterly and annual such as provider add audits, timely termination audits, benefit enhancement audits, and other ad hoc audits.
• Oversees and directs all operation, clinic, financial, quality team activities needed for the renewal or new applications for all CMS value-based programs such as Bundled Payment, Shared Savings and Full Risk models. Working with legal to ensure contracts are created and provider engagement for execution, compliance to ensure other policies and plans need to be created, care management teams, provider engagement, quality team, analytics.
• Works with finance for benchmark reports, pbp calculations, escrow accounts, financial guarantee and other agreements needed by the value-based programs.
• Supports operations integration needed to facilitate beneficiary notifications in the EMR, real time notification needs, quality measure identification, or subject matter support/education for ops teams.
• Must independently master key policy decisions and understand changes in programs or proposed programs developed. Report and share information with leadership
• SWHR Liaison and fields all operations questions internally and externally to regulatory program where needed.
• Must attend and facilitate operations teams to engage in webinars, presentations, surveys, face-to-face, virtual connection portals, access to CMS various systems etc.
• Oversee and develop process to ensure all policies and programs are adhered to with little risk to SWHR.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org