Network Contracting Specialist

📁
Manager & Professional
💼
ConnectiCare
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Summary:

Negotiate hospital, ancillary and physician contracts that are competitively priced in the market; maintain contractual relationships between the Plan and provider.  Manage, with direction of senior management, medical costs at network and non-network providers.  Work with provider to obtain signed contract or amendment.  Review contract(s) to identify “outlier” facilities to be targeted for re-contracting to reduce medical costs.  Maintain relationship between EmblemHealth and the providers in assigned region(s).  Ensure all CT and NYS DOH and CMS contractual obligations are met including contract compliance and network adequacy

Responsibilities:

  • Responsible for negotiating financial and other terms of hospital, ancillary and physician contracts utilizing internal end-to-end process.
  • Manage providers in all matters related to contract disputes; ensure accurate contract and rate load implementations. 
  • Communicate independently with providers; respond to provider inquiries in a timely, accurate, professional manner.
  • Work with detailed financial models, analyze information and data; calibrate and develop cost scenarios to effectively and accurately to ensure appropriate decision making on negotiations. 
  • Analyze geographic needs and referral patterns for ancillary and physician services; recruit providers of these services to ensure sufficient success and contracted rates for all services utilized/required through the network.
  • Manage claim inquiries and complaints for the assigned Hospital, ancillary or physician network: coordinate Joint Operating Committees (JOCs), claim review and resolution, and site visits to address provider’s concerns; communicate with appropriate parties on network issues including representatives of the delivery system and related business areas.
  • Ensure/coordinate notification and education of various departments within the EH on contract terms and related claims issues and conditions. 
  • Assist in the recommendation of innovative contracting strategies to maximize cost containment, access and quality through provider arrangements; remain current on provider reimbursement methodologies; and identify provider reimbursement trends to assist in the development of provider contracting strategies
  • Work with Director/Vice President to develop strategy for contracting on a go forward basis to manage unit cost and network adequacy

 

Qualifications:

  • Bachelor’s degree; Masters’ preferred.
  • 4 – 6 years’ experience in network management related role, such as contracting, or provider service required.
  • Knowledge of provider contracting methodology and payor roles, responsibilities and challenges required.
  • Understanding of health care financing, access, delivery systems, quality controls, and related healthcare legislation required.
  • Proficient with MS Office (Word, Excel, PowerPoint, Outlook, etc. required.
  • Detail orientation; organizational / prioritization abilities; proven ability to effectively manage multiple tasks/projects required.
  • Excellent communication skills (verbal, written, presentation, interpersonal) with all types/levels of audience required.
  • Proven ability to interact with high level individuals (CEO, CFO, VP Managed Care) at various provider organizations required.

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