Develops and maintains a cost effective, quality network of providers. Negotiates contact language for the physician segment of Peoples health provider network, including analyzing contracts, processing and documenting contract language changes, reimbursement methodologies, contract maintenance and subsequent amendments/addendums and resolving provider contract/reimbursement issues. Analysis includes review of contract and all other business-related documentation, confirmation of approvals and execution of contracts and reimbursement.
Assists Network Development in oversight and coordination of all contracts involving physicians. Assists in development, maintenance and daily operation of provider contract management database. Develops processes to manage documents involved with contracting physicians. Organizes and maintains documentation necessary for compliance with physician contracting regulations. Provides additional support, as needed, to the Network Development and Contract Administration departments, as well as the Provider Relations department.
- Evaluation, development and monitoring of Provider Networks
- Auditing and evaluating Network reimbursements
- Quarterly analysis meeting with providers to review reimbursements
- Contracting providers
- Securing Letters of Agreement for Non-contracted providers
- Monthly review of capitation reports
- Monthly review of out-of-network/out of network claims and referral reports
- Maintain provider contract language updates when changes need to be made
- Obtain Letter of Agreement (LOA) for non-contracted provider upon approval
- Obtain Covering PhysicianAgreements (CPAs) for contracted providers in respective Physician Team
- Acts as a liaison between providers and upper management
- Work with Provider Relations Representative to maintain a seamless working relationship with providers
- Maintain an up-to-date knowledge of products and member benefits
- Present Network profiles to other PH departments
- Knowledge of goals and objectives to other departments, i.e. ND Administration, Provider Relations, Marketing, Medical Management, Enrollment, Member Services and Finance
Bachelor's degree highly preferred; Minimum of 4 years managed care experience dealing with hospitals, physicians and/or ancillary providers required. Previous managed care experience a plus! Must have experience with Word, Outlook, Excel and e-mail applications. Must be able to manage multiple projects with the ability to determine project urgency. Should be able to adapt well to changing priorities, deadlines and directions. Excellent presentation skills as well as excellent communication skills are required.
Peoples Health, Inc. - 2 years ago
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