JOB DESCRIPTION FOR JOB TITLE:

UW HEALTH JOB DESCRIPTION

MANAGED CARE PROGRAM MANAGER

Job Code: 312002

FLSA Status: Exempt

Mgt. Approval: J. Nowicki

Date: October 2021

Department: Finance – Managed Care Contracting

HR Approval: S. Whitlock

Date: October 2021

JOB SUMMARY

The Managed Care Program Manager is responsible for the development and maintenance of health plan and payer

relationships. This position leads negotiations with managed care companies and health plans for agreements on behalf of

the entire UW Health system, including UW Health-Northern Illinois, UnityPoint Health – Meriter, UW Rehabilitation Hospital

and other entities. There are currently 15 entities to consider for each agreement. Depending on the entity, the Program

Manager interacts with Directors, VPs and CEOs to ensure that agreements meet the entity’s strategic goals in terms of

revenue, market position and operations. These entities include: UWHC, UWMF, UWH – Northern Illinois, Madison Surgery

Center, Transformations Surgery Center, Generations Fertility Care, Wisconsin Sleep, Chartwell, UW Rehabilitation

Hospital, UnityPoint Health-Meriter and any new joint ventures in these negotiations and in these relationships. The

Program Manager is responsible for ensuring the achievement of contract terms and conditions which are favorable to

these entities.

This position develops strategic planning for the entities and the payer relationships to achieve the financial goals of the

organization. The Program Manager plans for negotiations to achieve financial targets, cover our market regions, maintain

strong language terms and improve operational issues. This planning includes development of overall language,

operational and financial improvements as well as careful evaluation of contracts open for negotiation, including

identification of risks. These planning efforts represent about 30% of the Program Manager’s time. The financial terms of

these agreements drive the financial performance of the organization. These agreements represent 75% of the revenues

for UWHC and UWMF. Payer relations throughout the year are managed carefully to achieve specific goals.

This position manages, maintains and develops relationships with strategically important third-party payers requiring

significant experience in the field, as well as knowledge of the industry and provider systems. The Program Manager leads

negotiations with executives at the health plan or payer. These negotiations may be contentious regarding operational

issues, language complexities or rates, and the Program Manager role is to maintain a personal relationship while

advocating strongly for the provider systems. In the rapidly changing health care environment, the Program Manager is in

frequent discussions with the payer representatives throughout the term of the agreements, not solely during negotiations.

With well over 100 contracts and individual rates for the various provider entities, these agreements are complex and

require great attention to detail.

The Program Manager coordinates with all the various provider operational departments, business offices and Revenue

Cycle departments to ensure that operational matters relating to revenue cycle management are incorporated into

contracts. The incumbent works with medical school departments and hospital departments to develop payer and health

plan strategy and to troubleshoot issues. This position also communicates internally within UW Health and will develop

effective presentations or memorandums to present to a wide audience of leaders and staff, within UWHC, UWMF, the

Medical School or the other represented entities.

MAJOR RESPONSIBILITIES

Department Leader

• Interprets impact of broad scope organizational change for Managed Care and legal agreements. Develops change

strategies for successful implementation.

• Incorporates UW Health’s vision, mission and values in goals for negotiations within Managed Care

• Formulates objectives, goals and strategies collaboratively with other stakeholders throughout the enterprise and

with Joint Venture affiliates for financial, operational and clinical goals.

• Prepares and delivers reports to leadership at UW, UPH-Meriter and affiliates outlining progress towards meeting

goals and objectives, including financial performance.

• Develops future short- and long-term plans for each system and affiliate payer relations, including plans for

operational improvements to reduce administrative burden of payer requirements and plans for financial

performance of individual contracts and the overall contract portfolio, considering the overall payer mix for each

entity. This planning involves work with analysts, coordination with financial leaders of the provider entities as well

as revenue cycle leadership.

Negotiation

UW HEALTH JOB DESCRIPTION

• Responsible for the direct negotiation of a large portion of UW Health managed care contracts to achieve strategic

contracting goals with a variety of health plans, payers and products.

• Respond to market opportunities and monitor significant market changes to protect and enhance market share for

UW Health

• Meet with health plans for negotiation of rates and language, including development of agendas, preparation for

negotiations and generally lead the meeting and negotiate key topics

• Develop contract language to achieve UW Health results, update, review and revise contract templates, revise

health plan language to maintain compliance with State and Federal laws and specific provider entities’

requirements

• Ensure language meets the operational and financial needs of UW Health and other provider entities

• Evaluate financial performance and review trends for specific payers and comparison payers (within same

portfolio), plan to meet financial targets, understand various provider reimbursement methodologies (hospital,

physician, surgery center) and stay abreast of changing payment models

• Represent UW Health and the various entities in negotiations

• Manage the annual contract renegotiations ensuring that priority contracts are renewed prior to the termination

date.

• Quote and advise on UW Health contract rates and negotiates rates as described by the Managed Care partner on

the specific contract. Work directly with CFOs and other managers from provider entities on financial goals for the

specific contract.

Relationship Building with Payer and Health Plans

• Ensure client satisfaction through professional interactions on the phone, via email or mail and in person, building a

relationship with the counterpart at the payer/plan, along with other directors and leaders in the payer/plan

organization.

• Conduct orientations to UW Health for the payer/plan.

• Attend conferences with payer representatives, including representing UW Health at conferences, as a sponsor or

contributor. Makes site visits and/or travels to payer/plan location as needed.

• Stay abreast of changes in the insurance or payer market.

• Organize meetings with payers, organize educational sessions, engage physician leaders as needed, coordinate

and assist with case manager conferences.

• Address operational issues (clinical or business office) and facilitate solutions between the parties (can be patterns

of issues or specific claims or urgent patient needs).

Coordination with Internal Departments across the enterprise on Contract Administration

• Ensure contract language and final documents incorporate important revenue cycle management terms and

conditions.

• Develop systems for communication on important contract terms, payer newsletters and any significant changes

• Manage communication to these departments and remove barriers for operations or communications, which

include Provider Enrollment, Patient Resources, Prior Auth and the Access Center, Pharmacy, Rehabilitation

Medicine, Revenue Cycle, Clinic Operations, etc. Escalate issues to leaders as needed.

• Establish and maintain effective working relationships with physician leaders, physicians, department

administrators, Service line managers, senior leaders at UW Health and other provider entities’ management staff.

• Communicate pertinent contract information to all provider entities

• Facilitate operations meetings between internal provider departments and payers

• Troubleshoot and engage with specific departments or clinics as needed

• Oversee maintenance of the contract database

Develop and Maintain Contract Templates

• Develop contract language for templates and ensure language is in compliance with Federal and State laws and

supports UW Health’s requirements, as well as SAHS, UPH-Meriter and other entities.

• Review with Legal counsel

• Review with Revenue Cycle Teams

• Stay abreast of regulation and legal changes

Delegated Credentialing/Provider Enrollment

• Manage the enrollment and credentialing process for UW Health.

UW HEALTH JOB DESCRIPTION

• Complete delegated credentialing agreements, working with UW Medical Staff Affairs and other hospital’s

credentialing managers .

• Coordinate with various Provider Enrollment departments for processes and policies with new and changing

contracts

• Coordinate with various Marketing departments to ensure provider update processes are updated for new or

changing contracts

• Coordinate and distribute certificates, licenses and other documents with all the provider entities to meet payer

requirements.

Serve as Liaison to other constituents

• Serve as liaison to UW Health Strategy Office, including participation on committees, maintain relationship and

provide communication to UHC leadership

• Coordinate and communicate with UWH-Northern Illinois, UnityPoint Health-Meriter, UW Rehabilitation Hospital,

Chartwell Midwest Wisconsin and other relationships as assigned.

• Coordinate with other administrative and clinical department leaders within UW Health on contract issues and

payer relations, including Quality and Safety Innovation, Population Health, Clinic Operations and Academic

Departments.

• Serve as main point of contact for contract and payer relations for specific entities

Other duties and responsibilities

• Serve on Managed Care Steering Committee, and other various committees.

• Prepare and deliver presentations as needed to various UW Health committees

• Remain current on the health insurance market, changes in legislation, contract compliance issues and the provider

market.

• Provide back-up coverage for the other Contracting Specialists during their absences.

• Assist with budget process

• Other duties as assigned

ALL DUTIES AND REQUIREMENTS MUST BE PERFORMED CONSISTENT WITH THE UW HEALTH

PERFORMANCE STANDARDS.

JOB REQUIREMENTS

Education

Minimum

Bachelor’s degree from an accredited college or university. Four (4) years of

experience may be considered in lieu of the degree in addition to the experience

below.

Preferred

Master’s degree

Work Experience

Minimum

Two (2) years’ experience in healthcare organization or health insurance

industry

Preferred

Experience in a large healthcare organization or academic medical center

Professional or leadership/Negotiator roles in insurance and/or payer

organization

Licenses & Certifications

Minimum

Preferred

Required Skills, Knowledge, and Abilities

• Advanced knowledge of computer systems and ability to effectively utilize

software applications including spreadsheet, , word processing, calendar

and email. Experience in a MS Windows PC environment is preferred.

• Proven track record in negotiations. Ability to achieve stretch goals in

difficult circumstances.

• Professional demeanor and ability to handle challenging communications

when necessary and communicate complex concepts (written and verbal).

• Excellent organizational, time management, and problem-solving skills.

• Attention to the language and rate details in contracts.

• Ability to meet deadlines while managing multiple tasks.

• Ability to track, edit and monitor complex contracts with multiple language

changes and a series of addenda.

• Ability to work across organizations, develop relationships, promote

teamwork and represent physicians and hospital interests

UW HEALTH JOB DESCRIPTION

• Effective interpersonal relations skills promoting teamwork and collaborative

alliances.

• Knowledge of health care, health plans, managed care insurance

• Knowledge of principles and techniques used in negotiation

AGE SPECIFIC COMPETENCY (Clinical jobs only)

Identify age-specific competencies for direct and indirect patient care providers who regularly assess, manage and treat patients.

Instructions: Indicate the age groups of patients served either by direct or indirect patient care by checking the

appropriate boxes below. Next,

Infants (Birth – 11 months)

Adolescent (13 – 19 years)

Toddlers (1 – 3 years)

Young Adult (20 – 40 years)

Preschool (4 – 5 years)

Middle Adult (41 – 65 years)

School Age (6 – 12 years)

Older Adult (Over 65 years)

JOB FUNCTIONS

Review the employee’s job description and identify each essential function that is performed differently based on the age group of the

patient.

PHYSICAL REQUIREMENTS

Indicate the appropriate physical requirements of this job in the course of a shift. Note: reasonable accommodations

may be made available for individuals with disabilities to perform the essential functions of this position.

Physical Demand Level

Occasional

Up to 33% of the time

Frequent

34%-66% of the time

Constant

67%-100% of the

time

Sedentary: Ability to lift up to 10 pounds maximum and

occasionally lifting and/or carrying such articles as dockets,

ledgers and small tools. Although a sedentary job is defined as

one, which involves sitting, a certain amount of walking and

standing is often necessary in carrying out job duties. Jobs are

sedentary if walking and standing are required only occasionally

and other sedentary criteria are met.

Up to 10#

Negligible

Light: Ability to lift up to 20 pounds maximum with frequent

lifting and/or carrying of objects weighing up to 10

pounds. Even though the weight lifted may only be a negligible

amount, a job is in this category when it requires walking or

standing to a significant degree.

Up to 20#

Up to 10# or requires

significant walking or

standing, or requires

pushing/pulling of

arm/leg controls

Negligible or

constant push/pull of

items of negligible

weight

Medium: Ability to lift up to 50 pounds maximum with

frequent lifting/and or carrying objects weighing up to 25

pounds.

20-50#

10-25#

Negligible-10#

Heavy: Ability to lift up to 100 pounds maximum with frequent

lifting and/or carrying objects weighing up to 50 pounds.

50-100#

25-50#

10-20#

Very Heavy: Ability to lift over 100 pounds with frequent

lifting and/or carrying objects weighing over 50 pounds.

Over 100#

Over 50#

Over 20#

Other - list any other physical requirements or bona fide

occupational qualifications not indicated above:

Note: The purpose of this document is to describe the general nature and level of work performed by personnel so classified;

it is not intended to serve as an inclusive list of all responsibilities associated with this position.