Healthcare Contracting Specialist

Description

Position Summary

Manages physician contracting and network development functions for developing, executing and maintaining a provider network strategy statewide. Works in concert with medical management and the Provider Servicing Department in developing actions to meet market growth and medical cost targets.

Duties and Responsibilities

• Primary duty of negotiating and executing provider contracts.

• Leads research for any Institution, Network and/or Ancillary needs using all tools available; including but not limited to: WebMD, Health Plan websites, hospitals, google, etc.

• Provider networks contracting for initial network development and/or expansion in accordance with Company goals and standards.

• Meet with the appropriate physician personnel and fully explain the Company’s protocol, which includes all requirements necessary to comply with standards identified in the Provider Manual.

• Collects complete credentialing packets per specified health plan and according to the Networks Credentialing checklist from network physicians during the contracting process.

• Ensures that the provider network consists of Board Certified/Board Eligible Specialists and/or Ancillary providers as contracted by the network.

• Manages physician network by developing relationships to drive business results within assigned geographic area.

• Liaison in conjunction with Contracting and Credentialing Coordinator, for all health plans on all new contracting inquiries.

• Obtains leads for prospective physicians, manages all incoming new provider leads and follows-up with the providers on the status of their new contractual agreement per the Department’s Policies and Procedures.

• Strategizes to close all quarterly assigned Geo Access deficiencies per specialty and health plan.

• Special projects as assigned or directed.

• Negotiating and executing hospital contracts.

• Maintaining and updating current CRM platform (Monday.com) to reflect progress of ongoing leads negotiations.

Requirements

Travel

Yes, 95% of the time or as otherwise required by the company throughout the following Regions:

• Region 6: Hardee, Highlands, Hillsborough, Manatee and Polk
• Region 8: Charlotte, Collier, DeSoto, Glades, Hendry, Lee, and Sarasota

Knowledge

• A bachelor’s degree in a related field or equivalent experience related Network Development or Provider Relations experience.

• Minimum three (3) years’ experience in Medicaid/Medicare is preferred.

• Healthcare, provider office or HMO/PPO background preferred.

• Strong knowledge of regulatory requirements concerning Medicare and Medicaid.

Skills

• Excellent problem-solving skills.

• Excellent oral and written communication skills.

• Bilingual language skills a plus.

• Intermediate or stronger skill level with MS Word, Excel, Outlook and PowerPoint.