The Director of Managed Care serves as the leader responsible for the strategy, execution, and performance of all managed care activities across both fee‐for‐service (FFS) and value‐based care (VBC) arrangements. Reporting to the Vice President of Insurance Networks, this role oversees the teams responsible for contract negotiations, payer relations, medical economics, reimbursement modeling, and value‐based program performance. The Director leads the development, negotiation, implementation, and monitoring of all hospital, physician, ambulatory, and ancillary managed care agreements. This includes ensuring accurate contract configuration, optimizing reimbursement, and driving payer accountability. The role also provides executive oversight of the organization's value‐based payment portfolio—including shared savings, downside risk, bundled payments, and capitation—ensuring the system achieves quality, cost, and financial targets. This leader collaborates closely with Finance, Revenue Cycle, Population Health, Clinical Operations, and site CFOs to align contracting strategy with organizational goals, support growth initiatives, and develop the annual hospital revenue budget. The Director is a key architect of the system's managed care strategy and a central driver of enterprise‐wide financial performance.
Key Responsibilities
System‐Wide Managed Care Leadership:
Provide oversight for all managed care contracting across the system, including hospitals, physician enterprise, ambulatory centers, ancillaries, and value‐based arrangements.
Develop and execute contracting strategies that anticipate market shifts, payer policy changes, and regulatory developments.
Lead the creation of innovative contract structures that support system‐wide financial, operational, and quality goals.
Build and maintain strong payer relationships, ensuring transparency, accountability, and alignment with organizational priorities.
Oversee credentialing, billing, reimbursement, and payer policy interpretation in collaboration with internal stakeholders.
Oversight of Fee‐for‐Service & Value‐Based Performance:
Direct the teams responsible for FFS and VBC analytics, modeling, and performance monitoring.
Ensure accurate pricing of claims through Epic contract configuration and partner with Revenue Cycle to optimize contractual performance metrics.
Lead the development, valuation, and tracking of all value‐based programs, including shared savings, bundled payments, downside risk, and capitation.
Monitor payer performance, utilization trends, and reimbursement outcomes to identify opportunities for improvement and risk mitigation.
Guide the organization's strategy for bundled payment programs and participate in system‐wide risk‐based program development.
Medical Economics & Financial Strategy:
Provide strategic oversight of medical economics functions, ensuring accurate modeling, forecasting, and financial impact analyses.
Direct analytical resources to evaluate alternative contract proposals, quantify financial implications, and support negotiation strategy.
Review and approve analyses related to payer policy changes, regulatory updates, and reimbursement shifts.
Oversee the maintenance of detailed utilization and payment databases, ensuring accurate benchmarking and performance tracking.
Monitor cash realization relative to contract value and develop strategies to address denials, underpayments, and payment deprivation.
Network Management:
Oversee network adequacy and access standards for the system's self‐insured employee health plan.
Negotiate reimbursement terms with community providers to support Tier 1 network growth and cost containment.
Develop standing rate agreements that enable bundled and episodic risk programs.
Leadership & Collaboration:
Lead, mentor, and develop teams across contracting, payer relations, and medical economics.
Foster a culture of collaboration, transparency, and innovation.
Communicate complex concepts clearly to executives, physicians, and cross‐functional partners.
Represent Managed Care in system‐wide initiatives, interdisciplinary workgroups, and strategic planning efforts.
Qualifications:
EducationBachelor's degree in Healthcare Administration, Business, Public Health, STEM, or related field required. Master's degree in Health or Business Administration strongly preferred.
Experience & Requirements:
Minimum of six years of managerial experience in managed care, health insurance, or payer contracting, with exposure to both hospital and physician environments.
Extensive experience in contract negotiation, payer relations, and managed care compliance.
Proven ability to manage networks of hospital, physician, and ambulatory providers.
Strong understanding of patient accounting, billing, collections, and reimbursement analysis.
