Responsibilities
Manage the provider contracting process for a rapidly growing health plan, including Assuring that negotiators are efficient in their use of the correct documentsAssuring that contracts are meeting standardsAssuring contracts flow smoothly through the processes and that Claims
Operations can load the contract into our claim system.
- Collaborate with network contracting colleagues, as well as legal department, compliance, credentialing and claim operations to optimize and streamline the contracting process.
- Establish an end-to-end provider contract review policy and procedure incorporating the negotiation of language and rates to the entry in the claim system
- Manage all policies and procedures impacting the network development and credentialing teams; including development of new processes
- Lead the market fee schedule governance committee and ensure compliance with federal and state regulations
- Own and update the provider resources, as needed, to comply with regulations or expansion; including but not limited to the Provider Manual
- Identify potential risks associated with contracting activities and propose mitigation strategies
- Assist with internal and external audits
- Partner with Compliance to ensure all network filings are timely and accurate; including participation with Compliance to ensure adherence to established guidelines supporting Mental Health Parity
- Create and maintain a library of approved Model Contracts for hospitals, physicians / group, and ancillary providers
- Reduce / eliminate rework or mitigation of unfavorable contract terms over time
Position Requirements
- Bachelor’s degree or equivalent experience in related field, including 7+ years of work experience beyond degree within provider contracting and / or health insurance
- Remote with occasional travel (5%)
- 7+ years of experience with health plan or provider organizations
- Superior problem solving, decision-making, negotiating skills, contract language and financial acumen
- Experience with physician group and ancillary provider contracting language and reimbursement
- Experience reviewing delegated credentialing agreements
- Demonstrated experience in seeking out, building and nurturing strong internal and external relationships
- Team player with proven ability to develop strong working relationships within a fast-paced organization
- Customer centric and interpersonal skills are required.
Network Operations Manager
Collaborate with network contracting colleagues, as well as legal department, compliance, credentialing and claim operations to optimize and streamline the contracting process. Operations can load the contract into our claim system. Manage all policies and procedures impacting the network developmen...
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