AGC - Managed Care
Our client is a leading Nonprofit health system, dedicated to providing comprehensive care through hospitals, clinics, and urgent care centers across multiple states. The organization focuses on elevating the health of individuals and communities, guided by values of dignity, integrity, and compassion.
The Managed Care Counsel provides legal services for managed care contract negotiation, interpretation, management, and dispute resolution for healthcare providers within a healthcare system. Responsibilities include contract drafting, project management, and resolving managed care issues related to federal or state law changes, healthcare operations, and transactions.
Key Responsibilities:
- Analyze, draft, and negotiate key language terms of managed care contracts.
- Assist in the development of managed care contracting strategies.
- Conduct accurate and timely due diligence review of managed care contracts for proposed transactions.
- Analyze and clearly explain the implications of new and existing laws and proposed managed care contracting provisions to Managed Care and other business leaders.
- Actively oversee and participate in strategic analysis for managed care arbitration and litigation.
Required Knowledge and Skills:
- Strong working knowledge and understanding of the regulatory framework of health plans, including applicable federal and state laws.
- General familiarity with the operations and regulation of hospitals and other healthcare facilities and providers.
- Experience with operational and regulatory issues relating to internal and external claims reviews, network adequacy requirements, Internal Review Organizations (IROs), standard commercial payor contracting provisions, Medicare Advantage, Medicare secondary payment rules, Accountable Care Organizations (ACOs), the Affordable Care Act, and the No Surprises Act.
- Understanding of healthcare operational and regulatory matters, including general billing and reimbursement, electronic medical records (EMRs), HIPAA privacy and security regulations, the Anti-Kickback Statute, the Stark Law, beneficiary inducement prohibitions, and the False Claims Act.
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