System Director, Progress Health
The System Director of Progress Health (PH) is responsible for providing management direction and focus over the operations of Sinai Health System’s Physician Hospital Organization (PHO) PH. The System Director develops effective operating systems and processes for PH; builds and enhances PH relationships with MCOs and providers; builds the PH provider network by contracting with high quality physicians, ancillary providers and service providers cross the care continuum; develops data system infrastructure to ensure efficient management and PH’s demonstration of high quality care, outcomes and maximization of contract bonus potential; identifies and implements best practices for operations and sharing of knowledge to enhance the service and technical quality of the organization. The System Director, Progress Health reports to the Vice President, Physician Services/Executive Director of Progress Health and provides supervision to Progress Health Managers and Staff.
- Works collaboratively with the Chief Financial Officer (CFO) and System Director of Managed Care to negotiate contracts with managed care organizations (MCOs).
- Assists in contract review and the development of negotiating strategies and contract requirements that enhance PH’s opportunity for successful and efficient operations while permitting the participation of the broadest provider network within PH.
- Operationalizes PH MCO agreements and ensures revenue maximization from those agreements.
- Develops payer performance and monitoring tools for PH.
- Develops and defines potential managed care and financial models in which PH may participate and contract scenarios for target contract opportunities and models including: narrow networks, global payment including capitation, gain sharing and pay-for-performance; shared savings programs such as pay-for-performance; and major chronic illness programs (cancer, cardiac, orthopedic).
- Models benefit design of contracts and agreements to determine impact on PH member hospitals and providers.
- Develops and distributes a management dashboard that includes measures of PH results for financial, quality, utilization management, and growth indicators.
- Develops an efficient credentialing process that ensures PH has delegated credentialing approved with MCOs that provide it and that PH providers have efficient access to MCO enrollees.
- Acts as a managed care resource to all departments of the organization and works with System.
- Follows SHS guidelines related to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
- Develops an effective and efficient data system for management of capitation, collection and reporting of quality, patient satisfaction and clinical data as well as utilization management.
- Facilitates education on managed care and PH operations with internal and external customers.
- Develops and implements an effective utilization review (UM) infrastructure in conjunction with the PH Medical Directors and consistent with MCO contract requirements.
- Manages the preparation of agendas and meeting minutes for the PH Board of Directors, Utilization Review (UM) Committee and Quality Committee as well as other Board functions.
- Manages the daily operations of PH including its third party administrator relationship with Chicagoland’s Medical Services Organization (CMSO).
- Participates in development, implementation and maintenance of polices, objectives, short and long term planning and develops and implements projects and programs for PH to accomplish these established goals.
- Develops and manages the PH sales program to ensure the extension of the PH provider network and capture of market share.
- Resolves contractual disputes with the MCOs and assists the System Director of Managed Care in the negotiation of settlements.
- Develops and implements a new provider orientation program and onboarding process.
- Develops and maintains the PH operating policies and procedure manual and ensures the distribution of the manual to providers, referring physicians and staff.
- Identifies and pursues growth opportunities for network development including the recruitment of participating hospitals and providers.
- Maintains strict confidentiality.
Bachelor’s Degree in Business or related field (Master’s preferred), with at least ten years of healthcare experience, including healthcare contracting for hospital and provider services.
Knowledge & Skills:
Extensive knowledge of managed care practices/principles, payer reimbursement methodologies, contract modeling and managed care requirements/strategies will also be expected, as well as an understanding of the contract negotiation process, contract language, capitation management and data systems management. Superior presentation, oral/written communication, analytical, organizational and interpersonal and negotiation skills are required.