Provider Relations Contracting and Network Specialist

Job Description

Job Description

JOB SUMMARY 

Initiates dialog with prospective providers/ancillary providers (including, but not limited to, hospitals, skilled nursing facilities, skilled home healthcare agencies, and ambulatory surgical centers) based on business needs. Service providers to facilitate provider understanding of Plan Policies and Contractual Requirements. Develop and maintain positive working relationships with participating providers. Conduct analysis of business need and maintains network in compliance with business need; collaborates with marketing/sales and family practice center staff. 

 

RESPONSIBILITIES 

• Review, analyze, negotiate, implement, and maintain existing contracts with an understanding of professional rate schedules and contractual language.
• Identify network development opportunities through financial analysis, client requests, and product development.
• Define performance improvement opportunities.
• Assist with initial applications for completeness, timeliness, and accuracy in accordance with established guidelines.
• Assist with provider orientation and training.
• Facilitate interdepartmental collaboration to resolve complex provider issues related to contracting and contract configuration.
• Manages territory, inclusive of strategic network partnerships and the Plan's family health centers.
• Provides general instruction and support on USFHP products, provider manual, provider directory, Plan policies and Plan procedures.
• Research, resolve, and respond to provider/ancillary provider inquiries including, but not limited to, participation requirements, credentialing requirements, credentialing status, contract terms, fee schedules, reimbursement, utilization, access/availability standards, member eligibility, consult report requirements, etc.
• Document and track inquiries received and resolution.
• Monitor contract performance through site visits, claims and data analysis.
• Monitor quality and regulatory compliance and participate in annual HEDIS activities.
• Assist with Provider Panel Report Cards and Scorecard 
• All other duties as assigned by management 

YEARS OF EXPERIENCE 

• min. of 2 years’ experience in a provider contracting role with existing marketing relationships; experience with value based contracting a plus.
• 3- 5 years’ experience working with providers including medical groups, ancillary vendors, and allied health professionals.

 

TECHNICAL SKILLS/COMPETENCIES  

• Familiar with various reimbursement models including DRG, fee for service, bundle payments, etc.
• Industry payment rules, billing, coding, etc. a plus.
• Proficiency in Microsoft Office (2010) Word, Excel, PowerPoint, and Access.
• Must be organized and detail oriented.
• Ability to meet stringent deadlines and adjust priorities with business needs.
• Ability to reprioritize and adjust workload.
• Excellent communication & analytical skills.
• Experience with SalesForce.

 

EDUCATION/CERTIFICATION/LICENSE  

• BA/BS required 

 

SALARY RANGE: $85,000.00-$90,000.00 

 

Benefits Statement:

SVCMC, Inc. provides a robust benefits package that includes medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services. Employees also receive vision coverage through UnitedHealthcare Vision and dental benefits through MetLife. Basic life and disability insurance are automatically provided at no cost. All employees are eligible for commuter benefits, tuition reimbursement, and a 401(k)retirement plan with an immediate employer match that is fully vested from day one. SVCMC also offers a generous time off package, which includes vacation, 10 paid holidays, and 3 personal days. Additionally, employees have access to a comprehensive Employee Assistance Program and exclusive discounts through Working Advantage.

S VCMC IS AN EQUAL OPPORTUNITY EMPLOYER – ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO VETERAN STATUS, DISABILITY, OR  OTHER CHARACTERISTICS PROTECTED BY LAW. 

HYBRID Work Schedule:
Mondays & Fridays Remote.
Tuesdays through Thursdays in office.
8:30 am - 4:30 pm