Responsible for network development; negotiating, monitoring and managing the contractual relationships of assigned providers. Working in coordination with Compliance, Legal, Provider Relations, and Credentialing, and under the direction of Senior Provider Contract Specialist, Manager, Senior Manager or Director, negotiates and finalizes provider contract language and rates, including amendments for existing contracts and establishment of new ones. Contracts for physician, hospital, ancillary, behavioral health, and LTSS providers for Medicaid, Health Insurance Marketplace, Medicare, and any other programs Community may develop. Responsible for provider contract compliance, including regulatory network adequacy requirements. Coordinates with Network Management, Claims, and the Provider Data Integrity team, among others, to ensure adequate set up and comprehensive interpretation of new contract reimbursement and requirements. Assists with provider profiling, working with Provider Relations, Member Services, Provider Services, Healthcare Analytics to provide applicable reports, assist with analysis and recommend actions. Contributes to growth and expansion of the provider networks for any and all existing and/or new lines of business, which may include external meetings with prospective or existing providers for the purposes of negotiating or renegotiating agreements.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Negotiate hospital, physician, ancillary, behavioral health and LTSS provider contract language and rates using established parameters/guidelines.
Serve as a liaison between Community and its providers to facilitate communications, identify issues; resolve problems as they develop, and achieve smooth operations
Contributes to growth and expansion of the provider networks for any and all existing and/or new lines of business, which may include external meetings with prospective or existing providers for the purposes of negotiating or renegotiating agreements.
Assure compliance with regulatory requirements and product requirements related to provider contracting functions, including ensuring network adequacy requirements are satisfied.
Other duties as assigned.
Education/Specialized Training/Licensure: High School Diploma or Equivalent required. Bachelor's Degree preferred.
Work Experience (Years and Area): 2 years experience Healthcare, Providers/Managed Care, Contracting and Relations with degree required.
4 years related healthcare experience in lieu of degree required.
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, Outlook) required.
Other: Must Have Vehicle and Valid State of Texas Drivers License required.
Experience with Star Plus, LTSS, HCBPs, and Medicare products a plus.