Director, Managed Care Contracting - Revenue & Reimbursement - 40hrs

Connecticut Children’s is one of the nation’s leading pediatric health systems, dedicated to improving the health and well-being of children across Connecticut and beyond. The Director, Managed Care Contracting is a senior strategic leader and key member of the Finance Leadership Team, reporting directly to the Chief Financial Officer. This role owns Connecticut Children’s managed care contracting function end-to-end—leading payer strategy, contract negotiations, compliance, and payer relationship management across the hospital, outpatient departments, and specialty group. The Director serves as the organization’s primary expert on reimbursement strategy and payer economics, translating contract performance into actionable financial insight that supports organizational growth and mission. This is a high-impact leadership role for a strategic operator who can drive contracting outcomes, build lasting payer partnerships, and develop a high-performing managed care team.

Contracting & Negotiations-30%

• Directly manage and develop a portfolio of managed care contracts for Connecticut Children's hospital, outpatient departments, and specialty group; serve as the primary contracting lead for all facilities.
• Lead managed care contracting strategy, including analysis of contract and rate proposals, development of counter-proposal terms, and negotiation meetings with payers.
• Review all existing payer agreements and recommend alternative contractual language where ambiguous or detrimental terms and provisions exist.
• Develop and negotiate provider agreements and contractual payment terms for the medical center and affiliate organizations, including developing payment models for facility managed care contracts.
• Direct contract modeling activities, including what-if analysis using contract modeling tools (e.g., STRATA or equivalent), to assess feasibility of different payment methodologies and utilization patterns and their financial impact on Connecticut Children's.
• Research and apply global billing payment models, value-based care structures, and alternative risk-based methodologies. Challenge organizational assumptions based on data to drive change and ensure contracting success.
• Research and develop pay-for-performance models and Episode of Care payment methodologies under ACO or other alternative risk models. Work with Connecticut Children's accountable care organization to coordinate contracting efforts and outcomes beneficial to providers.
• Monitor market trends and competitive managed care products to develop strategy recommendations; develop strategic pricing within payer agreements that aligns with organizational priorities and growth initiatives.
• Represent managed care contracting interests in organizational efforts to build integrated networks, partnerships, and value-based arrangements.

Compliance, Regulatory & Reporting-35%

• Maintain advanced knowledge of third-party regulations (CMS, NCDHHS, DOI, and equivalent Connecticut agencies) for all payers, including governmental and commercial payers; ensure organizational adherence to applicable requirements.
• Ensure all regulatory, government, and agency data submissions (e.g., CHA, CHCA) related to managed care are completed accurately and on time.
• Lead the response to audit requests related to managed care contracts and payer-related matters for annual financial statement audits and external or payer audits. When requested, interface with external and third-party auditors; prepare and defend contract questions and challenges.
• Support government relations and executive leadership in assessing and quantifying Medicaid financial metrics related to managed care policy or reimbursement changes. Make recommendations to help shape Connecticut Children's response to policy or rate changes.
• Oversee hospital contract loading in Epic and management of hospital payment variances and facility credentialing as they relate to managed care operations. Attend Epic User Group meetings and training as appropriate.
• Work closely with Finance and Revenue Cycle teams to ensure reported data is reliable and that contract-related information is accurately reflected in financial reporting.

Payer Relations & Performance-35%

• Build and direct Connecticut Children's relationships with area managed care plans; cultivate lasting partnerships that support organizational goals and contract performance.
• Develop and maintain payer scorecards to highlight performance strengths and opportunities relative to contract terms. Actively partner with payer representatives to improve both Connecticut Children's performance and payer compliance with contract obligations.
• Oversee problem solving related to contract terms, payment promptness, payer-member issues, and physician-payer relations.
• Serve as the primary contact for physicians, Patient Financial Services (PFS), Billing, and Remittance staff for payer-related questions; act as liaison to payers for prompt issue resolution.
• Act as hospital and specialty group finance liaison during Joint Operating Committee (JOC) meetings with managed care organizations and PFS representatives.

Performs Other Duties as Assigned.

Education and/or Experience Required:

• Education: Bachelor's degree in Business Administration, Healthcare Management, Accounting, Finance, or a related discipline.
• Experience: 
  • Minimum of 10 years of progressive experience in managed care contracting required.
  • Minimum of 5 years of experience in a multi-hospital or health system setting.
  • At least 5 years of management and leadership experience.

Education and/or Experience Preferred:

• Education:  Master's degree in Business Administration, Healthcare Management, Accounting, Finance, or a related discipline.
• Experience:  Demonstrated experience leading contract negotiations with commercial, Medicaid, and/or government payers in a hospital or health system setting.

License and/or Certification Required:

• None.

License and/or Certification Preferred:

• Certified Healthcare Financial Professional (CHFP), Certified Public Accountant (CPA), or Certified Revenue Cycle Representative (CRCR).

Knowledge, Skills and Abilities:

Knowledge:

• Advanced knowledge of managed care contracting, payer landscape, and reimbursement methodologies for hospital and professional services.
• Advanced knowledge of third-party payer requirements and state/federal regulations pertaining to hospital and professional reimbursement, including CMS, DOI, and applicable Connecticut regulatory agencies.
• Working knowledge of value-based care, risk-based contracting models, and alternative payment methodologies (e.g., ACOs, Episodes of Care, Pay-for-Performance).
• Advanced knowledge of healthcare finance, budgeting, and fiscal management concepts.
• Advanced knowledge of reporting systems and database structures to interpret and leverage contract performance data.
• Advanced knowledge of Epic contract management, contract loading, and proration functions.
• Working knowledge of contract modeling tools (e.g., STRATA or equivalent).

Skills:

• Proficiency in Microsoft Office Suite; working knowledge of Microsoft Windows operating system.
• Advanced verbal and written communication skills; ability to present effectively to small and large groups.
• Exceptional interpersonal skills and ability to interact effectively with medical center leadership, government agencies, physicians, and third-party payers.
• Skill in evaluating operations and procedures, formulating policy, and developing and implementing new contracting strategies.
• Experience with Epic and contract management tools.

Abilities:

• Accept responsibility for and direct all managed care department activities with a high degree of accountability and ownership.
• Delegate tasks appropriately and maximize value by focusing on high-impact strategic initiatives.
• Exercise independent judgment and manage sensitive information across a range of internal and external stakeholders.
• Organize resources, establish priorities, and develop and implement short- and long-range goals.
• Persuade and influence others through data-driven analysis and relationship-driven leadership.
• Foster a cooperative and high-performing work environment.
• Ensure quality outcomes and drive continuous improvement of contracting processes and workflows.