Contract Administrator

Job Description

To perform this job successfully, an individual must be able to perform the job description satisfactorily. This job description reflects management's assignment of essential functions; it does not prescribe or restrict the tasks that may be assigned. The requirements listed below are representative of the knowledge, skill, and ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Responsibilities

Responsible for sustaining and building assigned network with full panel of Primary Care Physicians and Specialists. Identify network needs and negotiate full agreements and Memorandums of Understandings with providers to ensure availability and accessibility for members. Produce contract documents with various reimbursement payment methodologies such as Fee for Service, Capitation, Flat rates, and Case Rates. Document redlining and collaboration with legal team. Determine financial responsibility. Knowledgeable of claims, authorizations, network management, credentialing and eligibility processing and DOFRs/FRMs. Knowledgeable of Medicare and Medicaid fee schedul es. Represent company vision and goals during field visits and onsite engagements.

Conduct remote and field physician recruitment, negotiations, and servicing while partnering with managed care conscious providers. Decipher financial models and determine budget impact while driving towards stipulated regional MLR targets. Coordinate with Medical Management and Network Management in processing provider adds and terminations. Negotiate agreements and amendments based on various payment methodologies such as Capitation, Fee for Service, Case Rate, and Flat Rates. Work with providers and coordinate with external and internal legal teams to ensure compliance and to obtain approvals for redlines. Conduct market analysis, in conjunction with Provider Contracting Ops team, for provider coverage and reimbursement requirements. Present negotiated arrangements to Network Management and/or executive leadership for approval and execution. Conduct rollout meetings for new capitated specialist agreements and establish and/or maintain JOC meeting cadence. May lead ongoing JOC and specialty cap provider servicing efforts. Coordinate with other business units to ensure communication is provided to all impacted internal departments and to network providers. Ensure system configuration set-up is complete in accordance with contractual arrangements and to mitigate capitation leakage. Ensure network adequacy in accordance with regulatory time and distance requirements. Support new onboarding activities for managed clients, new market expansions and new program rollouts. Load Contracts and Practitioners to contracting database application. Support other internal business units in resolving claims, authorizations, and eligibility issues. Support credentialing process by collecting documents for new and recredentialing applications. Coordinate and perform tasks to meet all regulatory requirements and execute Prospect’s and health plan’s policies and procedures. Research and resolve provider issues and disputes in accordance to contractual arrangements.

This position is remote w/Field Responsibilities (30% driving).

Qualifications

Required Education/Experience

5 years managed care physician contracting negotiations

Preferred Education/Experience

Four year college degree or higher or equivalent experience

Financial review and contract performance

Capitation compensation negotiations and implementation

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.