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JOB SUMMARY: Responsible for providing the Health Plan with an overall expertise in physician, physician group, hospital and ancillary healthcare contracting and provider reimbursement methodologies, taking the lead or assisting on Provider Relations projects in existing, expansion and new markets.
PRIMARY RESPONSIBILITIES: Effectively represent company in interaction and negotiation with the most senior clinical and administrative executives. Collaborate with the CEO/COO and other Health Plan senior management to determine the Plan’s Provider Relations and/or Provider contracting needs. Work with Health Plan senior management and lead or assist in the development of Provider network business plans, strategies and goals. Work with Health Plan senior management and lead or assist in the development of Provider network related earnings improvement initiatives as well as network growth and expansion initiatives. Develop and implement Provider Relations projects or assignments in support of Health Plan goals, Support CEO/COO in the strategic analysis and negotiation of all types of complex Provider contracts. Review financial information and, in collaboration with Medical Finance, develop effective reimbursement methodologies and strategies to achieve specific contracting and budgetary objectives. Monitor local market trends relative to Provider contracting, reimbursement and service, make recommendations to modify current processes and assist implementing changes, when necessary. Educate PR staff on the concepts and practice of Provider Marketing. Assume responsibility for development, implementation, operation and oversight of Provider Marketing efforts in collaboration with Sales and Marketing leader. Other tasks as assigned.
JOB REQUIREMENTS: Education and Expertise ▪ Master’s degree in business administration, healthcare administration or related field; ▪ Minimum ten (10) years experience in managed care, with minimum eight (8) years in managed care administration; experience with government programs preferred. ▪ Strong understanding of the healthcare industry, managed care and Provider financing. ▪ Knowledge of Medicaid reimbursement methodologies is desired. ▪ Experience in contracting with large, complex Provider organizations. Documented success in Provider contracting, recruitment, retention and service.
Certification and Licensure: Current driver’s license, and at minimum, state required amount of automobile insurance for state where automobile is licensed.
Knowledge and Skills ▪ Ability to successfully interact with senior executives of the organization as well as community Healthcare clinical professionals and business executives nationwide. ▪ Self starter and goal oriented. ▪ Computational and analytical skills related to Provider contracting and healthcare cost management. ▪ Ability to establish a strategic vision, set expectations and provide clear direction to individuals or departments being managed. ▪ Respect for and ability to work well with all levels within the organization and within the Provider community. ▪ Appreciation of cultural diversity and strong sensitivity towards target member population. ▪ Excellent communication, organizational and project management skills. ▪ Ability to prioritize and execute multiple complex projects in various markets simultaneously. ▪ Ability to complete projects/assignments accurately, on-time, on-budget and with a minimum amount of supervision. Understanding and appreciation of legal and regulatory environment relative to Provider Relations.
Physical Requirements ▪ Must be able to travel on common carriers, drive an automobile and adhere to company’s travel policy. Must be able to operate a computer, telephone and other commonly used business-related items. |
