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Provider Relations-Networking-Contracting WellCare - Provider & Hospital Contracting Careers

Network Management Representative Job

Full Job Title: Network Management Rep

Job Number: 1702863

Location: Phoenix, AZ

Date Posted: 7-13-2017

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
Report to: Manager, Network Mgmt
Location: Camelback Rd, Phoenix AZ 85016
Job Type: Salary/Exempt

Essential Functions:
  • 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
Additional Responsibilities:
  • 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.
Candidate Education:
  • 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
Candidate Experience:
  • 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 previous contracting experience
Candidate Skills:
  • 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
Technical Skills:
  • Required Intermediate Microsoft Word
  • Required Intermediate Microsoft Excel
  • Required Intermediate Microsoft Outlook

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Last Updated On: 12/9/2015