[Hiring] Managed Care Contracting and Performance Advisor @Guidehouse

Role Description

The Managed Care Contracting and Performance Advisor is responsible for strategic management, evaluation, negotiation, implementation, and ongoing performance monitoring of managed care contracts. This role partners closely with Finance, Revenue Cycle, Operations, Physician Services, and payer organizations to optimize reimbursement, mitigate contractual risk, improve operational performance, and maximize revenue opportunities across hospital and physician service lines. The position serves as a subject matter expert in managed care reimbursement methodologies, contract language interpretation, payer negotiations, and contract compliance, while driving initiatives that improve financial outcomes and payer relationships.

Essential Duties and Responsibilities:

• Contract Evaluation and Analysis:
  • Conduct comprehensive reviews and audits of existing managed care contracts to identify opportunities for reimbursement improvement, contract optimization, and renegotiation.
  • Perform financial modeling and reimbursement analyses to assess the impact of proposed rate changes, contract amendments, and new payer arrangements.
  • Evaluate contract language to identify operational, financial, and compliance risks.
  • Assess reimbursement methodologies, payment policies, authorization requirements, carve-outs, and contractual obligations to ensure alignment with organizational objectives.
  • Develop business cases and executive-level recommendations to support contract strategy decisions.
• Payer Negotiation and Relationship Management:
  • Develop and execute strategic negotiation plans for commercial, Medicare Advantage, Managed Medicaid, and other managed care payers.
  • Support payer negotiations involving reimbursement rates, contract language, payment methodologies, revenue protection provisions, and operational requirements.
  • Analyze payer proposals and prepare counterproposals supported by financial and operational data.
  • Maintain ongoing communication with payer representatives to resolve negotiation issues and facilitate contract execution.
  • Build and maintain productive payer relationships that support long-term organizational goals.
• Contract Implementation and Operational Support:
  • Coordinate implementation activities related to new or amended managed care agreements.
  • Collaborate with Finance, Revenue Cycle, Patient Access, Case Management, and Physician Services teams to ensure operational readiness.
  • Develop and maintain contract summaries, reimbursement guides, and reference materials that translate contract terms into operational requirements.
  • Support payer configuration, billing implementation, reimbursement validation, and operational education following contract execution.
  • Serve as a liaison between internal stakeholders and payer organizations to resolve contract interpretation questions and post-implementation issues.
• Performance Monitoring and Revenue Improvement:
  • Establish and monitor key performance indicators related to managed care contract performance, including reimbursement accuracy, denial trends, payment timeliness, underpayment activity, and revenue yield.
  • Partner with Revenue Cycle leadership to interpret contractual intent and support operational compliance with contract terms.
  • Investigate, escalate, and assist in resolving complex underpayment, denial, and reimbursement disputes.
  • Analyze payer performance trends and identify opportunities for revenue recovery and contract compliance improvements.
  • Prepare executive-level reports and presentations summarizing contract performance, negotiation progress, financial impact, and strategic recommendations.
• Strategic Initiatives:
  • Identify and evaluate new payer, IPA, medical group, and physician contracting opportunities.
  • Support physician network and medical group contracting strategies designed to expand patient access and referral opportunities.
  • Assist with value-based care, risk-based contracting, and alternative payment model initiatives as appropriate.
  • Contribute to the development of managed care strategies that support organizational growth, financial sustainability, and market expansion.

Qualifications

• Requires a bachelor's degree and a minimum 6-8+ years or an AA degree and 8-10+ years of prior relevant experience.
• Relevant experience coming from a healthcare provider, central business office environment, managed care, contracting, healthcare finance, payer relations, related healthcare administrative roles or revenue cycle outsourcing company.

Requirements

• Demonstrated experience negotiating managed care agreements with commercial and government-sponsored health plans.
• Experience performing reimbursement analyses, financial modeling, and contract reviews.
• Knowledge of hospital and physician reimbursement methodologies, including Medicare, Medicaid/Medi-Cal, DRG, APC, fee schedules, capitation, and value-based payment models.
• Strong understanding of managed care contract language and reimbursement structures.
• Advanced analytical and financial modeling skills.
• Ability to interpret complex contractual and reimbursement provisions.
• Negotiation, communication, and relationship-management skills.
• Ability to work effectively across multiple departments and levels of the organization.
• Strong project management and organizational skills.
• Proficiency in Microsoft Excel, PowerPoint, and healthcare financial analytics tools.

Benefits

• Medical, Rx, Dental & Vision Insurance
• Personal and Family Sick Time & Company Paid Holidays
• Position may be eligible for a discretionary variable incentive bonus
• Parental Leave
• 401(k) Retirement Plan
• Basic Life & Supplemental Life
• Health Savings Account, Dental/Vision & Dependent Care Flexible Spending Accounts
• Short-Term & Long-Term Disability
• Tuition Reimbursement, Personal Development & Learning Opportunities
• Skills Development & Certifications
• Employee Referral Program
• Corporate Sponsored Events & Community Outreach
• Emergency Back-Up Childcare Program