Performs network development and provider service functions for hospitals and selected physician and 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, attain medical cost targets and to deliver excellent customer service to providers.
DEPARTMENT: FL-Network Development
REPRTS TO: Sr, Dir Hospital Contracting
Additional Responsibilities:Candidate Education:
- Matrix leadership of multi-disciplinary, cross-functional teams to successfully conclude highly complex hospital, hospital system and hospital-affiliated physician negotiations with high-dollar impact.
- Proactively manages intricate & multi-faceted hospital-owned/hospital-affiliated physician contracting negotiations resulting in a improved integration with hospital system partners and more efficient cost structure.
- Provides leadership in executing major network cost savings "MEI" initiatives for all lines of business resulting in significant network cost savings/cost reductions.
- 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.
- Performs other duties as assigned.
- Required A Bachelor's Degree in a related field
- Required 6 years of experience in the healthcare sector (preferably HMO, PPO or hospital)
- Required 5 years of experience in direct hospital, ancillary, physician contracting and network development
- Required Other Knowledge of regulatory requirements concerning Medicare and Medicaid
Licenses and Certifications:
- Advanced Demonstrated interpersonal/verbal communication skills
- Advanced Demonstrated written communication skills
- Advanced Demonstrated customer service skills
- Intermediate Ability to work in a fast paced environment with changing priorities
- Advanced Demonstrated analytical skills
- Intermediate Demonstrated organizational skills
- Advanced Demonstrated negotiation skills
- Advanced Ability to effectively present information and respond to questions from families, members, and providers
- Advanced Knowledge of healthcare delivery
- Intermediate Other To remain calm under pressure
- Advanced Other Ability to identify unusual variation in medical costs and to assess impact of change
A license in one of the following is required:
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft PowerPoint
- Required Intermediate Microsoft Outlook