Manages physician contracting and network development functions for developing, executing and maintaining a provider network strategy statewide. Works in concert with medical management and the Provider Servicing Department in developing actions to meet market growth and medical cost targets.
Duties and Responsibilities
•Primary duty of negotiating and executing provider contracts.
•Leads research for any Institution, Network and/or Ancillary needs using all tools available; including but not limited to: WebMD, Health Plan websites, hospitals, google, etc.
•Provider networks contracting for initial network development and/or expansion in accordance with Company goals and standards.
•Meet with the appropriate physician personnel and fully explain the Company’s protocol, which includes all requirements necessary to comply with standards identified in the Provider Manual.
•Collects complete credentialing packets per specified health plan and according to the Networks Credentialing checklist from network physicians during the contracting process.
•Ensures that the provider network consists of Board Certified/Board Eligible Specialists and/or Ancillary providers as contracted by the network.
•Manages physician network by developing relationships to drive business results within assigned geographic area.
•Liaison in conjunction with Credentialing Coordinator, for all health plans on all new contracting inquiries.
•Obtains leads for prospective physicians, manages all incoming new provider leads and follows-up with the providers on the status of their new contractual agreement per the Department’s Policies and Procedures.
•Strategizes to close all quarterly assigned Geo Access deficiencies per specialty and health plan.
•Special projects as assigned or directed.
•A Bachelor’s Degree in a related field or equivalent experience related Network Development or Provider Relations experience.
•Minimum three (3) years’ experience in Medicaid/Medicare is preferred.
•Healthcare, provider office or HMO/PPO background preferred.
•Strong knowledge of regulatory requirements concerning Medicare and Medicaid.
•Excellent problem-solving skills.
•Excellent oral and written communication skills.
•Bilingual language skills a plus.
•Intermediate or stronger skill level with MS Word, Excel, Outlook and PowerPoint.
•Must be organized and have excellent time management capabilities.
•Ability to analyze data to identify trends and variance from goals.
The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.
Position Type/ Expected Hours of Work
This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.
This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Yes, 95% of the time or as otherwise required by the company.
Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.