Manages physician contracting, network development and provider relations for developing, executing and maintaining a provider network strategy. Works in concert with medical management and sales developing actions to meet market growth and medical cost targets. Provides service and education to network physicians/providers.
Department: Provider Relations
Reports to: Dir, Hospital Contracting
- Services, contracts and negotiates with primary care, specialty physicians and ancillary providers for all product lines in assigned markets.
- Manages physician network by developing and maintaining relationships to drive business results within a specific geographic area.
- Identifies strategies to achieve Medical Expense Initiatives (MEI).
- Performs ongoing research to identify new providers or areas of expansion in assigned market.
- Responds to provider's contract requests and inquiries.
- Analyzes network gaps and identifies providers to contract.
- Reviews and amends provider's contracts when necessary.
- Evaluates contracted network to ensure functionality.
- Assesses performance and contract rates of providers to ensure our network is cost efficient.
- Researches and develops relationships with non-contracted providers.
- Collects credentialing and required documents for newly contracted providers.
- Strategies for membership growth and retention.
- Performs special projects as assigned
- For smaller or emerging markets, the Network Management Representative may perform a dual role with Provider Relation duties. Some associates may perform one or all of the below Provider Relations duties:
- Completes new provider orientation for all applicable product lines.
- Conducts site visits to service providers to provides education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and review HEDIS information. Addresses RxEffect, P4P, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, et al.
- Achieves frequency goals to establish consistent and strong relationship with provider offices.
- Partners with local and national ancillary for appropriate vendor management and coordinates the transition of the delegated providers following a network termination.
- Provides oversight on claims issues. Follows up with providers accordingly.
- Monitors and supports providers using utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve and maintain regions.
- Understands and explains fee-for-service and risk contracts, and provides reporting on provider and/or Service Fund performance.
- Proactively strategies for membership growth and retention, through advanced communication to providers, as well as follow-up to gauge the response to that growth.
- Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.
- Ensures contract SLA's are met, such as meeting with PCP's and Specialists on a monthly, quarterly, or annual basis to address provider panels, after hour's availability and EMR meaningful use.
- Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.
- Partners with finance to identify Medical Expense Initiatives to take actions necessary to successfully complete those initiatives, and assess progress on achieving financial goals.
- Provides continual training to assigned providers on wellcare.com portal and other resources to assist with claims, authorizations, member benefits, etc.
- Required A Bachelor's Degree in a related field
- Required or equivalent work experience directly related to Network Development or Provider Relations with demonstrated ability to perform the job duties
- Required 2 years of experience in Provider Relations, Network Management, Hospital Contracting or related Provider Services position with demonstrated ability to perform the level of duties of the position
- Required 1 year of experience in managed care
- Required Other Previous contracting experience
Licenses and Certifications:
- Intermediate Demonstrated written communication skills
- Intermediate Demonstrated negotiation skills
- Intermediate Knowledge of healthcare delivery
- Intermediate Demonstrated customer service skills
- Intermediate Ability to represent the company with external constituents
- Intermediate Demonstrated interpersonal/verbal communication skills
- Intermediate Ability to multi-task
- Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records
- Intermediate Ability to work independently
- Intermediate Ability to work within tight timeframes and meet strict deadlines
- Intermediate Demonstrated analytical skills
- Intermediate Demonstrated organizational skills
A license in one of the following is required:
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook