The Manager, Contracts (Managed Care) is responsible for the negotiation, analysis and contract language of provider contracts which include but are not limited to Primary Care Physicians, Specialist Physicians, Primary Care Physician groups, Specialist Groups, Ancillary providers, Hospital Based Physicians and Hospital Contracts.
In addition, responsible for assisting in the development of provider networks which includes physician, ancillary and hospital contracting and performing ongoing network analysis to ensure adequate coverage of providers.
Assists in the identification of potential providers and recruits providers when necessary to assure adequate geographic and specialty coverage.
Essential Functions and Responsibilities of the Job * Assist the Director in their contract negotiations for the MCMF Networks. Assume responsibility for contract negotiations under the direct supervision of the Director. * Negotiates both simple and complex contracts with physicians, ancillary providers, and hospital providers for all MCMF networks. * Exhibits a working knowledge and understanding of different reimbursement methodologies such as fee-for-service, capitation, case rates, ASA etc. and is able to provide a comprehensive written documentation of that reimbursement methodology within a contract. * Coordinates communication within the department and between departments regarding existing or new contracts. * Develops contracts that can be loaded into the EPIC system so that it minimizes manual intervention of claims review. * Participates in the maintenance of relationships with providers within the network and assists in the recruitment of new providers. * Assists with the review and development of Requests for Proposals (RFPs) from providers when services are requested from Senior Management or Capitation Committee. * Assists department personnel in resolving contract disputes related to claim payments. * Develops and generates appropriate reports on size, magnitude, cost effectiveness and comparative marketability of all networks for internal and external customers. * Analyzes language and rate structures. * Work with Utilization Management and Medical Directors to ensure an adequate panel of contracted providers to service the network's membership. * Negotiate and implement approved Letters of Agreement with physicians and vendors when requested. * Perform any additional/miscellaneous duties as requested by the management team within the scope of knowledge/ability. * Participate in interdepartmental meetings as directed by the Director. Assist in resolving or completing those action items assigned by the Director. * Performs other duties as required.
Essential Job Outcomes * Negotiate new and existing contracts * Assist in monitoring existing contracts for opportunities to increase revenue or reduce cost * Coordinate communication within the department and between departments (as needed) through regular meetings and published information. * Collaborate with Claims, Medical Management and IT Departments to ensure contracts can be administered accurately and efficiently. * Assist in the process of analyzing, developing, maintaining and administering provider contracts, as required * Maintain legal requirements for the department and /or company * Assist in monitoring the provider network to identify contracting needs and performance related issues. * Assist Provider Relations in on-boarding new physicians * Assist departments is addressing contract inquires * Assists in working with providers on performance related issues. * Perform any additional/miscellaneous duties (not inclusive of job description) as requested by the management team within the scope of knowledge/ability.
Experience * At least 3-5 years’ experience negotiating provider contracts in managed care environment in an IPA, Medical Group, Hospital or Health Plan. * Experience working with providers, health plans, members and vendors. * Must be able to handle a high volume work load and effectively prioritize work to meet changing deadlines. * Must have excellent communication skills, problem solving and analytical skills; ability to interact effectively with providers and with at all levels within the organization. * Must be proficient in Microsoft Office applications including Word, Power Point, Excel and Outlook. * Knowledge of EPIC Tapestry is helpful. * Knowledge of the medical billing practices are helpful. * Exposure to benefits interpretation of contracts is helpful
Minimum Bachelors degree in healthcare administration, business, finance, accounting or other related field.