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Director Provider Contracting

2016-06-27 22:37:26

Job Type: Full Time only
Budget $: 100,000 - 200,000

Job description

Job SummaryPlans, organizes, staffs, and coordinates the activities of the Provider Contracts unit within the MHI Provider Network Strategy & Services Department. Works with Associate Vice President MHI Provider Network Strategy & Services, Plan Provider Network Management & Operations, senior management and Corporate stakeholders to develop and implement standardized provider contracts and contracting strategies. Essential Functions
Monitors and reports network adequacy for Medicare and Medicaid services.
Manages, trains and assists the Contract Managers and Contract Specialist(s). Interviews, hires and completes performance appraisals.
In conjunction with the Associate VP, oversees development of provider contracting strategies, identifying those specialties and geographic locations on which to concentrate resources for purposes of establishing a sufficient network of Participating Providers to serve the health care needs of membership.
Provides advise in preparation and negotiations of provider contracts and oversees negotiation of contracts in concert with established company guidelines with physicians, hospitals, and other health care providers.
Utilizes standardized contract templates and Pay for Performance strategies.
Developes and maintains Reimbursement Tolerance Parameters (across multiple specialties/ geographies). Oversees the development of new reimbursement models in concert with Associate VP and Senior leadership. Communicates new strategies to Corporate and applicable stakeholders for input. Utilizes Standardized system (Emptoris) to track Contract Negotiation activity on an ongoing basis throughout the year.
Utilizes sound reporting and analytical tools to develop and refine strategic work plans; participates on the management team and other committees addressing the strategic goals of the department and organization.
Oversees the maintenance of all Provider Contract Templates. Works with Legal, Corporate and applicable stakeholders ,on an as needed basis, to modify contract templates to ensure compliance with all contractual and/or regulatory requirements. State Plan / Department Specific Duties and Responsibilities
Performs market provider network analysis, assessment and recommendations for Corporate business development and stakeholders.
Performs provider outreach and recruitment in order to establish competitive provider networks that are compliant with applicable state/federal access requirements and built on contract and payment standards.
Promotes membership growth & retention with participating provider networks that are aligned with core mission, values and preventive care coordination model.
Ensures highly accurate provider claims and encounter data reporting arrangements resulting in improved satisfaction, funding, NCQA and HEDIS performance.
Implements provider reimbursements and Pay-For-Performance rewards based on data driven decision making and commensurate with applicable product/program funds.
Ensures compliance with all Medicare and Medicaid provider panel and network capacity and adequacy requirements. Produces and monitors weekly/monthly reports to track and monitor compliance with network adequacy reqirements.
Promotes strategies to reduce impactible member access grievances. Helps implement strategies as needed to achieve desire goals and reduce impactible member access grievances.
Travel requirement of 20% to 40%, or up to 80% for specified new market provider network development & contracting field work (not applicable to all Dept/Staff)
Manages the relationship with area agencies and community provider partners to support and advance initiatives.
Develops and implements strategies to comply with state, federal, NCQA, HEDIS initiatives and regulations. Knowledge/Skills/Abilities
Knowledge of Excel and Word
Demonstrated adaptability and flexibility to changes and response to new ideas and approaches
Ability to lead department/team projects and initiatives and complete tasks as assigned
Ability to organize, coordinate, and accomplish a high volume of work with minimum impact on quality
Superior interpretation and research skills in order to readily identify problems and get to the root cause and achieve prompt resolution to problems and issues, including analytical skills
Exceptional interpersonal relations skills
Excellent influencing and negotiating skills
Superior verbal and written communication skills Ability to abide by policies
Ability to maintain attendance to support required quality and quantity of work
Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers

Required Education:

Bachelor\'s Degree in a related field (Business Administration, etc.,) or equivalent experienceRequired Experience: 5 years experience in Healthcare Administration, Managed Care, Provider Contracting and/or Provider Services.
Experience managing/supervising employees.Required Licensure/Certification:

Preferred Education: