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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.
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
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
Licenses and Certifications: A license in one of the following is required: Technical Skills: