Job Summary & Dimensions
To develop and maintain existing and new provider networks that will ensure a full complimentary network of acute care and other facilities, this position negotiates and implements for all Highmark Delaware products and members. This position is responsible for assessing, defining, developing, negotiating, implementing, and evaluating contractual relationships between Highmark Delaware and acute care and other facility-based providers of health care services for all of the Plan's product lines. The incumbent is responsible for the development of situational analyses and critical payment/financial analysis/reports and hospital profiling materials for the formulation of individualized hospital/institutional contractual strategies.
- Requires a Bachelor's degree in business, finance, accounting, health administration or other related field from an accredited college or university. Masters degree preferred.
- Requires at least three (3) years experience in complex provider negotiations.
- Requires three (3) years business experience in managed care network development/management.
- Demonstrated PC proficiency and analytical ability in computer skills including word processing, spreadsheet, database, and presentation software.
- Demonstrated above-average knowledge with third party payment concepts, medical reimbursement, claims adjudication and claims pricing (DRG) calibrations and application of OPPS Reimbursement.
- Demonstrated knowledge in business law and the interpretation of contract provisions.
- Demonstrated knowledge of payment systems, and new coding/reimbursement audit systems, new technologies in the medical field and changes that effect ICD-9-CM, or successor codes and DRG's.
- Demonstrated above-average verbal communication, written communication and project management skills. (Incumbent will be expected to explain the nature and significance of information to individuals with widely varying backgrounds).
- Ability to analyze situations or determine relevant points and to use analysis as basis for proposing course of action. Excellent analytical and logical reasoning skills are imperative for the assessment of finalization, utilization and market research data used in determining payment levels for providers.
- Innovative, strategic and sound decision-making ability required in a fast-paced dynamic environment at a level of sophistication achieved through experience and skill development. Must possess professional demeanor and appearance.
Gateway Health Plan
- 2 years ago - save job