Performs network development and provider service functions for hospitals and selected ancillary providers within a Region/State. Works with finance, legal, medical management, sales, provider operations and provider service center personnel in developing actions to meet market growth and medical cost targets and excellent provider customer service .
- Negotiates and renegotiates contracts with assigned hospitals (and other providers as needed).
- Prepares and executes periodic contract escalators/amendments and changes related to Medicare or Medicaid
- Ensures all contracts/amendments meet regulatory guidelines for all products.
- Verifies contract terms and demographics are loaded correctly in company databases.
- Ensures contracts meet operating, financial and legal standards.
- Analyzes cost and utilization data to develop specific actions to manage medical cost trend.
- Ensures compliance with Medicaid and Medicare for all contracting and network development purposes.
- Performs provider education through in-service activities and regularly scheduled follow up with providers.
- Ensures that providers receive provider and hospital communications ie: letters, newsletters, training materials, etc. to educate and enhance relationships with providers.
- Creates and maintains strong relationships with internal and external contacts to support department goals.
- Perform other duties as assigned.
Education: A Bachelor's Degree in a related field or equivalent directly related experience.
Experience: 5 years of work experience in the healthcare sector (preferably at HMO, PPO, or hospital). 3 years experience in HMO provider/hospital/ancillary contracting and network development. Knowledge of regulatory requirements concerning Medicare and Medicaid.
Special Skills (e.g. 2nd language):
Strong oral and written communication skills sufficient to communicate clearly both complex and simple messages
Superior negotiating and customer service skills
Excellent analytical skills including ability to identify unusual variation in medical costs and to assess impact of change
Ability to work in a fast paced environment with changing priorities.
Ability to remain calm under pressure
Ability to organize tasks and work environment
Technical Skills/Requirements: Proficient in Microsoft Office such as Excel, Word, PowerPoint and Outlook