Provider Contracting Specialist
4 weeks ago
SUMMARY:
The Provider Contracting Specialist is responsible for negotiating, implementing, and maintaining contracts with healthcare providers, including ancillary providers, facilities, and independent physicians. This role also involves working with smaller hospitals, physician groups, and vendors as required by the Provider Contracting Manager or Director of Network Strategy & Management.
ESSENTIAL FUNCTIONS:
Contracts with healthcare providers in accordance with plan objectives and within target budget guidelines.
- Evaluates and monitors network provider adequacy, accessibility, and payment rate parity.
- Makes recommendations for provider network additions/consolidations, vendor additions or changes, or changes in provider payment arrangements.
- Negotiates contracts in accordance with established parameters.
- Coordinates implementation of executed contracts.
Perform research and analysis in support of HNE systems integrity and provider billing compliance.
- Provides support in the implementation and post-implementation verification of provider contract configuration and payment accuracy.
- Researches and identifies payment discrepancies as a result of HNE system issue(s) and/or provider billing anomalies.
- Assists in performing impact analysis of changes to fees and payment methodologies including comparisons between fixed fee schedules and various other payment arrangements.
Assist Provider Contracting Department with activities related to the evaluation, implementation and maintenance of other provider contracts as necessary.
Assist with special projects as necessary.
MINIMUM REQUIREMENTS:
Bachelor's degree with more than 2 years of experience in a managed care environment; clinical experience a plus or an equivalent combination of education and experience.
- Knowledge of provider contracting models and arrangements.
- Good knowledge of managed care products, policies and procedures.
- Effective communication and presentation skills.
- Strong computer skills including Microsoft Word, Excel, PowerPoint, Access, (knowledge of Amisys preferred but not required).
- Initiative, excellent judgment and superior problem solving skills.
- Strong customer orientation and ability to manage expectations and needs of all customers, both internal and external.
- Ability to balance multiple priorities across multiple lines of business: commercial, medicare, and medicaid.
- Represents HNE and its initiatives in a positive and professional manner.
- Ability to maintain poise, composure, and diplomacy in negotiations and when under pressure or challenged by internal and/or external demands.
- Ability to maintain forward momentum in negotiations even when the other party to the negotiation is being very difficult.
WORKING CONDITIONS: Works in a standard office-based environment.
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