Provider Contracting Specialist (REMOTE) ID-1750
PURPOSE:
This role is responsible for the building, management, oversight and negotiation of Institutional, Ancillary, Vendor, Dental and Professional contracts as well as the contracting of more complex high-performance provider networks. Performs duties to coordinate and support all types of provider contracting in accordance with guidelines in order to maintain and enhance the provider network and to meet accessibility, quality and financial goals.
ESSENTIAL FUNCTIONS:
- Successfully negotiates cost effective, competitive and complex contracts in focused regions that will produce savings to clients. Ensures the economic details in the contracts meet the need of key stakeholders. Manages the provider contract including negotiations, level of network participation, rates, payment levels, reimbursement methodologies, financial feasibility, performance monitoring and assessment, language and network adequacy. This includes negotiations, credentialing, financial quantification, network impacts, qualification and competitive analyses, implementation and monitoring of all contracts. Monitor Vendor Performance Standards and coordinate approval and assessment of penalties when appropriate. Facilitate and manage the implementation process of the negotiated terms with the Reimbursement Implementation department as well as the Provider Information and Credentialing department.
- Develop business cases and present findings to Senior Management to support reimbursement and contracting initiatives through statistical analysis, cost/benefit modeling and analysis. Develop and present business cases to support changes in network strategies including rates, payment methodologies and network configuration. Upon approval, develop and implement the network by sending out RFIs, establishing periodic financial targets, provider criteria for participation, contracts and amendments, renegotiate and manage targeted networks or institutions and gain consensus with other internal areas affected by network changes.
- Educates provider and their staff about the value proposition. Collaborates with the payment transformation department to develop and establish value based arrangements, alternative rate arrangements and ACO arrangements.
- Develop contracts in coordination with the Legal Department for any changes to standard contract templates. Work with Legal to develop and review any proposed language changes discussed with a provider. Ensure compliance with jurisdictional regulatory requirements and quality monitoring organizations (NCQA).
- Builds and maintains high performance complex medical networks to support the needs of the market and our clients.
- Participate in strategic project planning and positively contribute to strategic objectives for the department. Coordinate department activities to meet Corporate Project deliverables. Work with Quality Improvement, Legal, Care Management, Internal Audits and other departments to identify and support corporate initiatives (e.g., hospitalist, diabetes education, reduction of authorizations, reduction of claims appeals, etc.). Participate in internal and external committees and workgroups, to identify network improvements and areas of concern, implement resolutions and contribute to the implementation process of projects as it relates to institutional, ancillary, professional, dental and vendor contracting. Provide subject matter expertise on projects as needed. Also, represent division as the subject matter expert in support of BCBSA workgroups.
- Performs the provider credentialing as assigned, and data maintenance processes based on department policy, procedure, and standards and guidelines as indicated by NCQA guidelines. Incumbents are responsible for: 1) ensuring accurate and timely credentialing and subsequent submission of provider information to support claims submission, 2) ensuring submission of information that assures accurate and timely data for systematic provider demographics, 3) performing as the point of contact for the contracted institutions, ancillary providers and vendors and 4) assisting providers in obtaining insurance, privileges and/or other required credentialing and practice elements
- Work with Reimbursement Department to develop and monitor financial projections, including development of financial modeling tools and network metrics needed for ad hoc and recurring reports. Develop and Manage Request for Proposal process to evaluate, score and select Network Providers and /or Vendors in support of Corporate and Network initiatives.
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QUALIFICATIONS:
Education Level: Bachelor's Degree, Business, Finance, Health Care Administration or related discipline OR in lieu of a Bachelor's degree, an additional 4 years of relevant work experience is required in addition to the required work experience.
Experience: 2 years healthcare, business- or job-related field. 1 year experience in contracting, provider recruitment and/or provider relations
Preferred Qualifications:
- Masters degree in Business or Health Care Administration
Knowledge, Skills and Abilities (KSAs):
- Deep understanding of multiple reimbursement methodologies used in healthcare provider contracting.
- Proven ability to build strong collaborative business relationships.
- Understanding of contractual documents and ability to effectively communicate terms to providers.,
- Working knowledge of provider community, market and its underlying financial dynamics.
- Ability to function as a subject matter expert for assigned networks; ability to learn and use electronic contract management system.
- Effective negotiation skills.
- Superior PC skills, including financial analysis and modeling.
- Working knowledge of provider community, market and its underlying financial dynamics.
- Working knowledge of health care financial matters and third-party payment methodologies.
- Effective interpersonal skills in order to lead project teams towards goal attainment and ability to work independently and as part of a team.
- Effective time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
