FRANCES M. ORTIZ

Contract Strategy & Negotiation

• Directly negotiate managed care contracts to achieve strategic goals and maximize organizational value.
• Lead payer negotiations including rate and language discussions; prepare agendas, materials, and serve as lead negotiator for key terms.
• Draft, review, and refine contract language to ensure legal compliance, protect organizational interests, and support strategic initiatives.
• Design and implement innovative contract structures (e.g., risk-based agreements, value-based care models) aligned with institutional objectives.
• Maintain and update contract language templates to comply with state and federal regulations.
• Support negotiation and implementation of new healthcare contracts as needed.

Legal, Compliance & Risk Management

• Serve as liaison with healthcare attorneys during contract reviews, coordinating legal input and ensuring favorable, compliant contract terms.
• Analyze complex contract terms, special provisions, and legal conditions to ensure full regulatory and procedural compliance.
• Ensure adherence to delegated network responsibilities, including provider communications, notices, policies, reporting, annual audits, and corrective action plans.
• Conduct high-level review and analysis of contract issues, Medicare considerations, and cost implications.
• Monitor contract performance and key provisions, identifying improvement opportunities and ensuring compliance.

Cross-Functional Collaboration & Leadership

• Collaborate with senior leadership (CEO, CMO, Director of UM and Revenue Cycle) on provider network decisions, dispute resolution, and rate adjustments.
• Liaise with departments including Revenue Cycle, Utilization Management, Referrals, Credentialing, Marketing, and Compliance to align contract operations and strategy.
• Lead the Organization’s Contracting Committee, including meeting facilitation, agenda creation, and internal communication.
• Drive cross-functional project management initiatives to support strategic network and contracting goals.
• Serve as subject matter expert (SME) to internal stakeholders and mentor to less experienced team members.

Network Development & Operational Execution

• Oversee contracting efforts with network providers to develop narrow, efficient networks across multiple managed care plans.
• Manage provider compensation models, pricing strategies, and contract data analysis.
• Identify and control costs, implementing cost-saving initiatives and negotiating settlements as necessary.
• Resolve escalated issues related to claims, contract interpretation, provider data accuracy, and network development concerns.
• Lead health plan rollouts and operational implementation activities prior to go-live dates.
• Contribute to the design, integration, and management of strategic network configurations.
• Build and maintain strong relationships with providers and internal departments to ensure alignment and success.

Contracting & Network Development

• Manage the end-to-end contracting process between the organization, Network Providers, and Medicare Advantage health plans.
• Secure contracts to build an efficient, narrow network serving multiple managed care plans and patient populations.
• Support contract negotiations and implementation efforts for healthcare agreements as needed.
• Collaborate with CEO and CMO to review and approve network changes, including provider adds/deletes, rate changes, and dispute resolution.

Network Delegation & Compliance

• Ensure full compliance with all aspects of delegated network responsibilities, including provider communications, notices, policies, reporting, audits, and action plans.
• Participate in annual CMS delegation audits with National Health Plans, contributing to policy updates, contracting elements, data reporting, and corrective action planning.
• Resolve escalated issues related to claims payment, contract interpretation, demographic accuracy, and settlement negotiations.

Financial Oversight & Strategic Planning

• Conduct high-level analysis of contract terms, costs, and Medicare-specific considerations.
• Manage provider compensation models, pricing strategies, and contractual data.
• Identify cost-saving opportunities and lead implementation of settlement activities and efficiency initiatives.

Relationship Management & Leadership

• Serve as a subject matter expert (SME) for less experienced team members and internal stakeholders.
• Optimize provider and internal business partner interactions to ensure needs are met and goals are aligned.
• Lead and present Managed Care Orientation sessions for new hires.
• Assist in the design, development, and integration of strategic network configurations.

Contract Negotiation & Relationship Management

• Serve as liaison between the organization and MCO payers, including Medicaid, Medicare, and Workers' Compensation, to negotiate discounted rates and establish mutually beneficial Letters of Agreement (LOAs).
• Redline and review agreements to ensure contract language is equitable for all parties.
• Travel as needed to meet with payers and customers to discuss contract needs and strengthen partnerships.
• Build and maintain strong business relationships to streamline processes and enhance collaboration across stakeholders.
• Ensure patient and customer needs are prioritized, facilitating timely application of the VAC and minimizing out-of-pocket costs or placement delays.

Contract & Pricing Administration

• Manage and maintain both new and existing payer fee schedules within the Oracle system.
• Act as a liaison between multiple internal departments including Contract Administration, PFS/ARM Operations (claims, billing, collections, acute care), Managed Care Compliance, CPEG, IT Business Solutions, Global Supply Chain, Pricing Programs, and IS Development teams.
• Execute pricing policies in alignment with payer contracts and internal audit requirements.
• Identify and address training needs related to pricing and reimbursement within Contract Administration and PFS Operations to reduce claim denials and underpayments.

Process Improvement & Project Management

• Lead and contribute to cross-functional projects by offering strategic insights to improve workflow efficiency and operational outcomes.
• Develop and update Standard Operating Procedures (SOPs) and Functional Level Operations (FLOs) to reflect new or optimized processes.
• Identify and resolve recurring payer-related issues, implementing solutions that align with business and financial objectives.
• Gather and analyze data, conduct proof of concepts, and formulate strategic plans to support training, communication, and program development initiatives.