Director, Provider Contracting

Job Summary :

The Director, Provider Contracting executes contracting strategy, develops provisions based on cost, quality / analysis and monitors key metrics.

Essential Functions :

• Conduct annual effectiveness review of contracting strategies; ensure corporate compliance with all contracting
• Ensure an ongoing high level of staff engagement, empowerment and development
• Responsible for provider recruitment, implementation of contracts
• Responsible of contracts and testing, initiating set-up, post configuration testing, maintenance and audit of claims system
• Create contract language and review with legal to develop approved contract templates
• Administer provider contracts, terms, reimbursement rates, etc., in a manner that complies with corporate policies
• Implement an efficient and effective process to on-board new providers; ensure network is adequate (access for members), cost-effective, competitive and stable, and meets corporate & regulatory requirements
• Responsible for ensuring all regulatory requirements for provider network are met
• Perform gap analysis to ensure no gaps and / or sanctions occur; identify & implement solutions that mitigate risk; development of corrective action plans as needed
• Responsible for access grievance intake, analysis and performance improvement initiatives
• Participate in training sessions for providers and staff as appropriate
• Support the contracting requirements of the corporation for geographic regions and products
• Implement performance improvement initiatives to improve Provider Satisfaction Scores incrementally on an annual basis
• Assist with development and review of payment policies and provider notifications
• Collaborate with appropriate personnel with process of reassignment of members related to provider terminations, as required by the state
• Perform any other job related instruction as requested

Education and Experience :

• Bachelor’s degree in a healthcare related field, or equivalent work experience is required
• Master’s Degree or equivalent work experience is preferred
• Minimum three (3) years of contract negotiation experience is required
• Minimum three (3) years of management experience is required
• Managed care experience is highly preferred

Competencies, Knowledge and Skills :

• Intermediate proficiency level with Microsoft Outlook Word, and Excel
• Knowledge of Network Management Processes & Services
• Ability to manage and prioritize multiple tasks, promote teamwork and fact-based decision making
• Effective oral and written communication skills
• Critical listening and thinking skills
• Training / teaching skills
• Time management skills

Licensure and Certification :

To help protect our employees, members, and the communities we serve from acquiring communicable diseases, Influenza vaccination is a requirement of this position.

CareSource requires annual proof of Influenza vaccination for designated positions during Influenza season (October 1 March 31) as a condition of continued employment.

Employees hired during Influenza season will have thirty (30) days from their hire date to complete the required vaccination and have record of immunization verified.

CareSource adheres to all federal, state, and local regulations. CareSource provides reasonable accommodations to qualified individuals with disabilities or medical conditions, sincerely held religious beliefs, or as required by state law to enable the employee to perform the essential functions of the position.

Request for accommodations will be completed through an interactive review process.

Working Conditions :

• General office setting, noise level is generally quiet to moderate
• Perform reasonable travel, up to 30% to fulfill the duties of the position
8 days ago