Director Of Managed Care Contracting

ABOUT FULGENT

Fulgent is a leader in genetic and genomic clinical testing, a publicly traded company located in Los Angeles, California. We are a technology-driven company with extensive academic/clinical experience and capabilities in Next Generation Sequencing and bioinformatics. This distinction has advanced us to the forefront of the rapidly advancing genetic and genomic testing industry.

Fulgent's unique chemistries and superior proprietary bioinformatics pipeline has propelled our explosive growth in recent years. We offer the most expansive set of clinical genetic tests in the world, including 22,000+ single gene tests, 900+ preset panels, rearrangement testing, clinical exome/trios, whole exome/trios, whole genome and our All-in-One reflex test. We are a CLIA and CAP accredited laboratory. Fulgent has state-of-the-art clinical, sequencing and bioinformatics tools, including the latest Illumina sequencers such as the NovaSeq.

SUMMARY OF POSITION:

The Director of Managed Care Contracting is responsible for the overall development and implementation of payer partnerships and payer network strategy for Fulgent’s managed care program.

This position enhances Fulgent’s managed care program by (1) analyzing contract opportunities to increase and maintain market share, (2) developing payer contracting strategies, execution and key metrics, to include service and operation for different relationships to support payer-financial growth objectives, and (3) negotiating contracts with managed care companies and health plans, including HMOs, PPOs, and other products.

Our Director provides leadership to maintain effective payer partnerships through maintenance of relationships with internal and external sources involved in the contracting process; participation in the development of contract language and negotiation strategy in-depth financial analyses of contract performance and makes recommendations as to the desirability of canceling, renegotiations or extending contracts.

In this role, the Director of Managed Care Contracting also serves as a liaison with the Revenue Cycle department and other internal staff on implementation of contracts and compliance to contract terms to ensure providers are receiving appropriate reimbursement and that other contractual requirements are met.

KEY JOB ELEMENTS:

• Responsible for direct negotiation of Fulgent’s managed care contracts to achieve strategic contracting goals.
  • In coordination with Fulgent executive leadership, lead development and execution of Fulgent’s payer partnership strategy.
  • Develop strategy for contract relationships, including specific products (for ex: Medicare or Medicaid, HMO, PPO and other health plans).
  • Source and qualify opportunities for Fulgent to enter contracts and partnerships with payers and monitor significant market changes to protect and enhance market share.
  • Serve as a principal negotiator of payer contracts and partnerships on behalf of Fulgent.
  • Develop contract structures that are appropriate to the company (including the full range of reimbursement structures whether hospital, physician, ASC, bundled payments, capitation or other), consider cost of care or performance targets and make sense in relation to the size and scope of the contract.
  • Analyze significant and unique contract requirements, special provisions, terms and conditions to ensure compliance with appropriate laws, regulations, and Fulgent policies and business procedures.
  • Develop and analyze rates for proposals or counter-proposals.
  • Analyze the significance and value of potential contracts; determine the cost of care based on care delivery and contract structure. Project contract performance based on modeling of actual and representative samples.
  • Monitor contract performance and other provisions to ensure compliance, identify problem areas and resolve disputes.

2. Responsible for overseeing operations that develop and maintain positive relationships and financially viable contracts with payers and ongoing analysis of existing contracts for compliance and performance review as well as analysis for budgeting revenues, long-range planning:

• Analyze historical utilization and trends in revenues, by reviewing financial data reports to identify issues with operation of contracts.
• Update COO of contracting on unexpected changes in the planned performance of contracts
• Develop standard reports and maintain skills for ad hoc reports.
• Assist with reporting needs for budget purposes, revenue projections and long range planning.
• Engaged contacted network leaders and establishes and maintains positive business relationships.
• Make recommendations as to the desirability of canceling, renegotiations or extending contracts.
• Direct and support staff to achieve organizational goals by communicating job expectations, planning, monitoring and appraising job results, coaching and counseling, driving increased employee engagement.

3. Serve as Liaison with the Revenue Cycle and other operational departments regarding ongoing contract compliance to support key business functions:

• Address operational issues with payers by proactively identifying issues, and soliciting information and feedback from Revenue Cycle regarding implementation and performance of contracts.
• Determine how contracting department can assist with processes, communication or interpretation of language.
• Produce operational statistical reports to provide contracting team with necessary tools for effective decision making and strategy including analysis, trending and comparative data (cancellation reports, identifying trends in no referral/authorization, timely filing, no provider certification, A/R aging, & etc.).
• Work with Revenue Cycle in preparing Payer Scorecards for use during contract negotiations.
• Facilitate payer meetings, including preparing agendas, attending meetings, etc.

4. Assist with development of tools and procedures (for ex: summary grid information on contract terms and/or fiscal summaries, payment reports, timely filing deadlines, etc) for use by various operational departments, in particular to manage and provide oversight of other contracting staff such that these tools and internal processes ensure:

• Timely updates on renewals, amendments and other contract changes that need to be communicated.
• Continuous improvement for both populating the tools and ease of use of the tools.
• Dissemination of information to appropriate audience.

5. Lead the development of contract language that protects Fulgent’s best interest and satisfies strategic contracting objectives, including:

• Develop template language.
• Review and interpret non-standard contract language for appropriateness.
• Ensure specific requirements are included.
• Research and assist in the development of contract language for Medicare, and Medicaid agreements, ensuring state and Federal guidelines are being met.
• Evaluate requirements for out of state Medicaid HMO plans, make recommendations and coordinate with Revenue Cycle in interpretation/feasibility of non-standard requirements.

6. Research and investigate related laws or regulations for contracts, health insurance, coverage and related topics.

KNOWLEDGE / EXPERIENCE:

• Bachelors degree required, Graduate Degree in Healthcare Administration preferred not req’d
• Minimum of five years in healthcare payor contracting and reimbursement, either on the payor side or within a hospital or diagnostic laboratory setting.
• Strong and direct payor negotiating experience required. Required - highly proficient in Microsoft Excel, Word and Access including import/export functions. Required – strong written and verbal communication skills
• Minimum of 3 years of Customer Service experience in the health industry.
• Knowledge of and experience with CPT-4 and ICD-9 and HCPC billing, coding and posting charges in medical billing software.
• Knowledge of insurance guidelines including HMO/PPO, Medicare, Medicaid, and other payer requirements and systems.
• Knowledge of insurance plan benefits and terminology.
• Knowledge of and experience with contract payer policies and procedures.
• Knowledge of HIPPA compliance.
• Proficient in Microsoft Office Suite applications

SKILLS & ABILITIES:

• Handles multiple tasks simultaneously.
• Communicates effectively with all levels of staff.
• Maintains composure while working under high pressure.
• Demonstrates strong interpersonal skills that foster a positive environment.
• Demonstrates flexibility and ability to adapt to change.
• Excellent communication, time management, and computer skills.
• Must be accurate with attention to detail.
• Customer service skills for interacting with medical billing clients and patients regarding medical claims and payments.
• Ability to work well in a team environment. Being able to triage priorities, delegate tasks if needed, and handle conflict in a reasonable fashion.

SUPERVISORY RESPONSIBILITIES:

• YES

REPORTS TO:

• Chief Operating Officer

ENVIRONMENT:

Fulgent Therapeutics LLC is an Equal Employment Opportunity Employer.

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable qualified individuals with disabilities to perform the essential functions. The term “qualified individual with a disability” means an individual with a disability who, with or without reasonable accommodation, can perform the essential functions of the position.

Safety and Work Environment:

• General office environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
• Maintains a clean, neat, and orderly work area.
• Adheres to Department Specific Safety Guidelines.

Physical Demands:

• Standing, sitting, walking, bending, reaching, manual manipulation, and lifting up to 10 pounds.
• Must pass a color vision test if responsibilities require color discrimination.