Contract Specialist

5 days ago

Orange, United States Infojini Inc Full time

Job Description:


80% - Contracting Functions Negotiates, implements and manages provider network contracts, health networks, professional, ancillary and facility providers, as assigned. Negotiates LOA for members being directed to out of network providers for covered services, reviews requests for accuracy and appropriateness and attempts to identify opportunities to redirect member(s) to in-network providers, as needed. Maintains and reports the status of LOA dispositions, develops action plans to transition non-contracted providers to full contracts when possible and collaborates with other staff to monitor and expedite the credentialing/contracting process. Optimizes and maintains accuracy and integrity of new and existing provider contracts to ensure compliance with Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) mandates. Manages project plans when implementing network-wide contract initiatives. Coordinates with legal, Medical Management, Provider Relations, Finance and OneCare Sales and Marketing to implement new and renewing provider contracts. Monitors performance and utilization trends of assigned networks to assess new opportunities for cost savings, alternate delivery models and financial risk sharing through contractual arrangements. Works with leadership to identify and problem-solve provider contracting issues.

- Negotiates, implements and manages provider network contracts, health networks, professional, ancillary and facility providers, as assigned.

- Negotiates LOA for members being directed to out of network providers for covered services, reviews requests for accuracy and appropriateness and attempts to identify opportunities to redirect member(s) to in-network providers, as needed.

- Maintains and reports the status of LOA dispositions, develops action plans to transition non-contracted providers to full contracts when possible and collaborates with other staff to monitor and expedite the credentialing/contracting process.

- Optimizes and maintains accuracy and integrity of new and existing provider contracts to ensure compliance with Department of Health Care Services (DHCS) and Centers for Medicare & Medicaid Services (CMS) mandates.

- Manages project plans when implementing network-wide contract initiatives.

- Coordinates with legal, Medical Management, Provider Relations, Finance and OneCare Sales and Marketing to implement new and renewing provider contracts.

- Monitors performance and utilization trends of assigned networks to assess new opportunities for cost savings, alternate delivery models and financial risk sharing through contractual arrangements.

- Works with leadership to identify and problem-solve provider contracting issues.

- 15% - Administrative Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Assists the teams in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department. Develops desktop procedures, network overviews and identifies network nuances that improve processes and workflows.

- Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.

- Assists the teams in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

- Develops desktop procedures, network overviews and identifies network nuances that improve processes and workflows.

- 5% - Completes other projects and duties as assigned.


Minimum Qualifications:


- Bachelor's degree PLUS 4 years of experience with provider contracting, negotiation, hospital and delegated health network/medical group provider agreements or other complex provider contracts required; an equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above may also be qualifying.

- Experience with Medi-Cal and Medicare lines of business within a health plan or large health care delivery system required.

- Experience with Medi-Cal, Medicare fee-for-service reimbursement rates, and capitation methodologies required.


Preferred Qualifications:

- 4 years of contracting and network management experience in California with a health plan or large provider delivery system.


Knowledge & Abilities:

- Develop rapport and establish and maintain effective working relationships with clients Health's leadership and staff and external contacts at all levels and with diverse backgrounds.

- Work independently and exercise sound judgment.

- Communicate clearly and concisely, both orally and in writing.

- Work a flexible schedule; available to participate in evening and weekend events.

- Organize, be analytical, problem-solve and possess project management skills.

- Work in a fast-paced environment and in an efficient manner.

- Manage multiple projects and identify opportunities for internal and external collaboration.

- Motivate and lead multi-program teams and external committees/coalitions.

- Utilize computers and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.

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