• GENERAL SUMMARY

• The Leader of Contract Management is responsible for all aspects of payer contract negotiations, network management, and strategic partnerships for an integrated pediatric healthcare system. This pivotal role requires expert negotiation skills to ensure the health system secures optimal reimbursement, denial reduction, and access for its pediatric patient population while aligning contracts with the organization’s strategic goals. The role is primarily responsible for fostering collaborative relationships with managed care organizations (MCOs). The Leader of Contract Management works closely with a wide range of internal and external stakeholders, including finance, legal, compliance and clinical operations, to ensure that contracts support the organization’s mission. The ideal candidate possesses a deep understanding of managed care dynamics within a health care setting and is skilled in contract negotiations, financial analysis, and stakeholder management. Reports to department leadership.

• ESSENTIAL DUTIES AND RESPONSIBILITIES

• Contract Negotiation and Management: Lead negotiations with third-party payers, including commercial, Medicaid and value-based agreements, to secure favorable terms, rates, and conditions that support financial and strategic objectives. Manage contract compliance and analyze payer performance against payer agreements to ensure optimal reimbursement. Identify opportunities for improvement in payment terms, methodologies, and network participation.

• Contract Implementation and Monitoring: Ensure timely and accurate implementation of managed care agreements, including fee schedules, contract terms, and performance metrics. Monitor contract performance and compliance, identifying areas of under performance against negotiated terms and working with internal stakeholders to address issues. Ensure credentialing and revalidations are updated timely and accurately in the payer systems.

• Analysis and Strategy Development: Analyze managed care data to identify trends, and competitive intelligence, and financial outcomes and recommend improvements. Develop contracting strategies that optimize revenue, reimbursement rates, and patient access and address the unique needs of pediatric care, including specialty services and high-cost treatments.

• Revenue Cycle Optimization: Works closely with the revenue cycle team to identify and mitigate issues related to denials, underpayments, and reimbursement delays. Monitor financial performance metrics, including reimbursement rates, payer mix, and claims adjudication efficiency. Implement best practices to enhance payer contract performance and minimize revenue leakage.

• Payer and Relations Strategy: Build and maintain strong positive relationships with managed care organizations, third-party payers, and state and federal programs. Collaborate with leadership to develop and implement managed care strategies that align with organizational goals.

• Value-Based Care Initiatives: Lead efforts to integrate value-based care models and alternative payment strategies with payers. Monitor outcomes related to population health initiatives and adjust strategies as needed to optimize financial incentives. Collaborate with clinically integrated networks and clinical teams to ensure alignment between contract requirements and clinical care delivery models.

• Executive Director of Physician Health Organization (PHO): Serve as the Executive Director over a separately managed PHO entity. Provide strategic leadership, operational oversight, financial management, regulatory compliance management, and maintain stakeholder engagement.

• Credentialing and Revalidations: Oversee and manage the credentialing and process for providers within the health system, ensuring timely and accurate completion of all necessary documentation. Lead the revalidation efforts to maintain compliance with managed care organizations, Medicaid, and other payer credentialing requirements. Ensure that all providers are properly credentialed and revalidated with payers in a timely manner to avoid disruptions in reimbursement. Collaborate with the medical staff office, provider relations, and other relevant departments to streamline credentialing workflows and resolve any issues with payer participation.

• Compliance and Policy Development: Ensure contracts comply with all state and federal regulations, particularly Medicaid programs. Develop and update internal policies related to payer contracts, reimbursement methodologies, and managed care processes. Collaborate with legal, compliance and finance departments to ensure adherence to contractual and regulatory obligations.

• Payer Updates and Organizational Communications: Maintain oversight of all payer updates, including changes to reimbursement rates, policies, billing guidelines, and credentialing requirements. Ensure timely dissemination of payer updates to relevant departments, including revenue cycle, clinical operations, finance, and provider teams. Develop and implement communication strategies that ensure all stakeholders are informed of payer policy changes and their operational impacts. Act as a liaison between managed care organizations and internal departments to ensure updates are understood, incorporated into workflows, and acted upon. Create and distribute regular bulletins or summaries that highlight important payer changes and action steps,

• Cross-Department Education and Collaboration: Educate and train staff on contract terms, payer requirements, and best practices to ensure that the organization maximizes the benefits of managed care agreements. Collaborate with internal departments, including finance, revenue cycle, legal, compliance, and clinical operations, to ensure that contract terms are understood and operationalized effectively.

• Reporting and Analysis: Provide regular reporting dashboards and analysis to identify trends on payer mix, contract financial performance, impact of contract terms, reimbursement trends, and other key metrics to senior leadership, offering insights and recommendations for strategic decision-making. Use data-driven insights to guide contract negotiations and revenue optimization efforts.

• Market and Regulatory Knowledge: Stay current on industry trends, regulatory changes, and best practices. Apply this knowledge to enhance the contracting strategies and operations.

• Regulatory Compliance: Ensure that all managed care contracts comply with applicable laws, regulations, and industry standards, including those specific to pediatric care.

• Leads, manages, coaches, and trains a team or department, provides guidance, support, and mentors to ensure optimal performance and productivity.

• Oversees the recruitment, hiring, team/department orientation, performance appraisals and disciplinary actions including up to termination processes for a team or department.

• Performs other duties as assigned.

• LICENSES AND/OR CERTIFICATIONS

• None required.

• MINIMUM EDUCATION AND EXPERIENCE REQUIREMENTS

• Required Education and Experience

• A bachelor’s degree in business, healthcare administration, finance, or a related field is required.

• 7-10 years of experience in managed care contracting, network management, or payer relations within an integrated healthcare setting is required .

• Experience with data analysis, financial forecasting, and reporting tools required.

• Proven track record of optimizing payer contracts and enhancing financial performance.

• Demonstrated success in negotiating contracts with managed care organizations.

• Preferred Education and Experience

• Master’s in Business, Healthcare Administration, Finance, or a related field preferred.

• Strong knowledge of pediatric healthcare services preferred.

• Required Knowledge, Skills and Abilities

• Deep understanding of Medicaid, value-based care models, and reimbursement structures.

• Knowledge of federal and state healthcare regulations impacting managed care.

• Excellent negotiation, analytical, and problem-solving skills.

• Strong leadership skills with the ability to drive initiatives and influence outcomes.

• Strong interpersonal and communication skills, with the ability to build relationships and work collaboratively with a wide range of internal and external stakeholders.

• Detail-oriented with excellent organizational skills and the ability to manage multiple priorities.

• Strategic thinking with the ability to align payer strategies with clinical and financial goals.

• Ability to interpret complex contract language and financial data.

• Strong proficiency and technical aptitude in MS Office products (including Excel, PowerPoint, Outlook and Word) and contract management software.

• Ability to travel to various locations (payer meetings, industry conferences, etc.)

• WORKING CONDITIONS

• Normal office environment with little exposure to excessive noise, dust, and temperature; it may be an opportunity for remote work with an approved in-home setup to ensure compliance.

• PHYSICAL REQUIREMENTS

• Click here to view physical requirements. (https://www.chkd.org/uploadedFiles/Documents/Employees/Category%20A%20Jobs.pdf)

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