At Alliance Radiology, our team members focus on transforming the patient experience and delivering exceptional quality care. Alliance Radiology has rapidly grown over the past 30 years by providing radiology service line solutions, outpatient center management services, and mobile radiology solutions (Per Diem, PT, and FT MRI, PET/CT, CT).
The Lead Payor, Contract Negotiator is responsible for representing Alliance Health Care Services interests to the Payor, RBM and Broker community including conducting contract negotiations involving complex reimbursement structures designed to enhance and improve the revenue stream at the Radiology retail locations. Working in conjunction with the Sales and Marketing, AE, and regional operations teams develop financial analysis specific to each retail and wholesale location including Payor contracted rates, Medicare and Medicaid rates, worker’s compensation rates, total and variable cost per scan and the revenue impact of new and changing rates to be used in the development of a site level managed care strategy. Conduct Payor market research that includes all Payors in the specific retail or wholesale markets for potential new contracts, all Payors authorization and provider directory look up parameters, changes to the Payors payment policies and rates and new Payor product lines. Maintain regular and consistent contact with all contracted and non-contracted Payors so that there is advanced notice and awareness of planned fee schedule changes, new product lines, plan design changes, authorization guideline changes and the beginning or ending use of an RBM for all or particular services. Research assigned markets as well as unfamiliar territories for data related to the market dynamics including department of insurance available files, publically filed Medicare and Medicaid data, private data bases such as the Advisory Board and Definitive and client available data. Serve as a mentor to less experienced Payor Contract Negotiators through on-going instruction, coaching, modeling and counseling aimed at developing the type of skills and behaviors that will result in successful Payor negotiations.
Specific duties include, but are not limited to:
- Serves as the primary contact and liaison for Alliance Healthcare Services with all assigned Payors:
- Maintains regular contact with all assigned Payors via phone conversations and face to face meetings. Maintains Payor contact information for the primary, day to day, contact and their manager.
- Tracks and knows in advance all changes assigned Payors are planning related to fee schedules, new products, plan design changes, authorization guideline changes, and Payor use of an RBM.
- Monitors all changes to Medicare and Medicaid rates, coverage changes for new services and the addition of new CPT Codes. Understands and distributes changes to the regional management before they occur.
- Prepares analysis, reports and presentations by collecting, analyzing and summarizing Payor information and trends to be used in setting managed care strategy:
- Understands Payor market for all assigned Payors including Payors that are not contracted in that market and why.
- Has excellent understanding of both wholesale and retail Payors, and the market dynamics around both.
- Researches and develops market analysis in unfamiliar territories. Maintains knowledge of public data bases in each state and the available data needed to develop market analysis.
- Develops and uses analytics around competitive reimbursement to set managed care strategy and rates for a single Payor or group of Payors within a market.
- Maintains SharePoint locations analysis for both retail and wholesale fixed and mobile sites. Develops new analysis for new locations and refreshes data in the existing analysis every six months. Continually searches for new data elements to include in the analysis.
- Negotiates Payor contracts to support penetration and revenue objectives relative to competitive market trends and client expectations through comprehensive, aggressive execution of market specific contracting goals derived from national and regional objectives related to revenue and contractual terms improvement.
- Monitors and makes recommendations regarding the financial viability of all Payor contracts and works with the regional teams to ensure the financial viability of the contracted entities.
- Using superior negotiation skills, knows when and how to push back on Payor expectations to achieve desired financial results. Makes recommendations to the regional leadership around options in moving forward with less than optimal contract terms.
- Responsible for the schedule and coordination of contractual documentation for review with internal departments, develop draft changes to contracts and prepare necessary documents for effective presentation to Sr. Management.
- Audits and updates all contract language to Alliance Standards.
- Works directly with the legal and compliance department on a variety of legal and regulatory issues specific to Payor contracts, Medicare and Medicaid.
- Ensures all contract payment terms are loaded and processing correctly in the Alliance billing system. Ensures the Payor websites and directory parameters indicate the Alliance location as an active provider.
- Provides assistance to the Sr. Manager, Managed Care by:
- Participating in setting the managed care department annual goals and objectives as well as their own individual goals and objectives. Monitors results monthly and takes corrective action to ensure all goals are met by the specified timeframes.
- Participating on company-wide and regional operations project teams to implement and integrate new acquisition Payor agreements and team members.
- Providing guidance to less experienced Payor Contract Negotiators particularly related to analysis develop, setting a strategic approach to entering a Payor negotiation and developing aggressive counter proposals.
- Developing and maintaining training programs and manuals for the regional and managed care teams. Develop and review of policy and procedures.
- Works in conjunction with the AE’s, Sales and Marketing and the regional teams in responding to client needs or requests by:
- Participating in work groups designed to develop new fixed or mobile retail locations.
- Researching and communicating changes in Payor policy that is having or, can have, an adverse effect on the physicians, clients, patients or on the locations revenue.
- Amending Payor contracts with new location addresses, new tracer CPT Code rates and new products.
- Participates in client and physician calls when requested to provide specific expertise as a value add.