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.
Essential Duties and 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 contracts and reimbursement methodology with physicians, physician groups and IPA's, ancillary providers, LTSS providers and Hospitals, for Medicaid 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 contract 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 denials and underpayments, contracting for new services.
- Four-year Bachelor's degree or equivalent experience, required
- Minimum 5 years experience in Managed Care, either from provider or managed care company, or a combination of both is required with at least 3 years contract negotiation experience, required.
Specific knowledge, skills and abilities
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
- Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.