Managed Care - Contract Negotiator
- PRIMARY FUNCTION
- Responsible for contract management, assist with review of contract language between provider and payor, assist with the development and recruitment of provider(s) for narrow networks, ensure contracts comply according to Federal and State regulations. Supports the Director of Managed Care and Contracting Manager in strategic local market/national negotiations to include Risk and Value Based Contracting.
- ESSENTIAL FUNCTIONS OF THE JOB
- This list may not include all of the duties that may be assigned.
- Support the Contracting Manager in negotiations including Risk, Value Based, Fee for Service, and provider specific contracts
- Perform contract language review and support in negotiating language changes/terms/provisions with payors to maximize reimbursement, reduce exposure, and streamline administration
- Gather and analyze data for managed care contract negotiations
- Review and maintain contract renewal schedule to ensure contracts are negotiated timely
- Ensure provider compliance with contract terms and legal regulations
- Research all state and federal regulations that may impact the performance of the contract
- Identify contracting opportunities with existing payor Agreements
- Monitor contract financial performance including Capitation, Risk, Gainshare, Pay for Performance, and Bonus arrangements.
- Perform any other duties as assigned.
- PERFORMANCE REQUIREMENTS
- Bachelor’s degree preferred. AA plus a minimum of 5 years of related experience is commensurate to the education preferred.
Knowledge, Skills & Abilities:
1. Knowledge in Risk and Value Based Contracting
2. Effective strategic planning and organizational skills
3. Knowledge of Statewide Medicaid Managed Care programs and Commercial payors
4. Proficient in research, analysis, and interpretation of financial data and trends
5. Knowledge of reimbursement methodologies and CPT, ICD10, RBRVS, and capitation.
6. Knowledge of claims, credentialing, and loading processes
7. Advanced Microsoft Office skills
8. Effective oral and written communication skills
9. Ability to manage multiple priorities and projects
10. Strong interpersonal skills
- Minimum of 3 years’ experience required. Previous healthcare experience required.
Adhere to all organizational information security policies and protect all sensitive information including but not limited to ePHI and PHI in accordance with organizational policy, Federal, State, and local regulations.