Contract Manager HMO Providers (Health Plan) Job

Children's Health - HMO Careers

Job Number: 52198

Location: Dallas, TX

Date Posted: 8-19-2017

Description:

POSITION SUMMARY:

Responsible for negotiating and re-negotiating physician, hospital and ancillary provider contracts on behalf of Children's Medical Center Health Plan and all provider affiliates, in accordance with company standards, in order to maintain and enhance provider networks (Medicaid, Commercial and Medicare Advantage) while meeting and exceeding accessibility, quality and financial goals.

JOB PROFILE:

  • Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field.
  • Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands and the factors that differentiate the organization in the market.
  • Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements.
  • Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information.
  • Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies.
  • Works independently, receives minimal guidance.
  • Explains diffcult or sensitive information; works to build consensus.

JOB SPECIFIC RESPONSIBILITIES:

  • Analyzes existing network to develop strategies to maintain and improve access, quality and financial performance. Prepares recommendations and presents to leadership for approval. Negotiates contractes and reimbursement methodology with physicians, physician groups and IPA's, ancillary providers, LTSS providers and Hospitals for Mwewdicaid Managed Care and CHIP, Commercial HMP and PPO and Medicare Advantage products. Works collectively with internal departments to ensure contracts can be administered within existing policies and programs. Negotiates contract language and reimbursement methodology to achieve financial and contractual advantage.
  • Manages relationships and generates solutions with providers regarding issues related to onttract interpretation, reimbursement and other financial and administrative matters.
  • Knowledge of State and Federal laws and regulations pertaining to providers and provider agreements and specifically as a resource in regard to the UMCM, UMCC and TMHP guidelines.
  • Facilitates sharing of information internally as it relates to MCO updates, changes, contracts. This will be done via written and verbal communication.
  • Manages and leads projects assigned to network management, ensuring accurate and timely completion.
  • Identifies and implements opportunities to improve contract performance, including but not limited to enhanced reimbursement, reduction in denails and underpayments, contracting for new services.

QUALIFICATIONS;

Experience:

  • Minimum 5 years of experience in Managed Care, either from provider or managed care company, or a combination of both is required.
  • At least 3 years experience with contract negotiations is required.

Education:

  • Bachelor's Degree or equivalent experience is required.

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