· Serves as the "point person" to the leadership teams for all managed care contract related aspects, including contract performance, operational issues, negotiation activities, and strategic planning.
· Works with provider relations and claims to investigate and resolve reimbursement issues identified.
· Identifies payment trends and works with leadership including finance and medical management to identify and negotiate improved contracts.
· Carries out appropriate managed care related education and training including roll out of new contracts independently or in partnership with provider relations.
· Assures that new contracts are appropriately reviewed and are rolled out in a timely, accurate manner.
· Assures that new contracts are implemented correctly in the management information systems.
· Routinely validates the correctness and accuracy of the network in the management information system, in the directory and on the web-sites.
· Maintains paper contracts in an organized manner and secures them in a safe environment.
· Assists in payor/plan dispute resolution projects as appropriate.
· Responsible for distribution of managed care related information to appropriate parties within USFHP and CHP.
· Responsible for working closely with the credentialing department to obtain all necessary information at the time of contracting to fully coordinating facility credentialing & re-credentialing activities.
· Develops and prepares required reporting, and meets all state and federal reporting timelines.
· Maintains the ability to produce Geo Access Maps in a timely manner including training of staff in the network or providers relations department.
· Develops department specific metrics, and reports to internal committee including any corrective action plans for identified deficits.
· Educates key associates as to the contracting process/methodology, as needed.
· Maintains and fosters relationships with large, key providers.
· Knowledge of general Federal and applicable State regulatory environment related to managed care and participates in legislative advocacy activities as appropriate.
· Routinely reviews contracts to ensure compliance with State and federal regulations. Ensures proper contract approvals through regulatory bodies.