3-4 years of progressive provider network contracting experience
In-depth knowledge of contract finance and provider reimbursement methodologies, including risk, shared savings, pay-for-performance and other financial incentive strategies
Proven negotiation skills with hospitals, Integrated Delivery Networks, physicians and ancillary service providers
Knowledge of federal and state Medicare, Medicaid, and relevant guidelines, regulations and standards
Requirements:
Leads negotiations of financial and other contractual terms in all lines of business
Manages provider implementation to ensure provider hierarchy and data are loaded correctly across systems and communicates unique arrangements
Ensures provider compliance with contractual, regulatory and NCQA requirements and standards
Gathers and analyzes data to assess provider network adequacy against standards and business expectations and develops improvement strategies
Job description
The Contract Manager facilitates development, implementation and management of new and current cost-effective provider networks for multiple products. Under the direction of the NH Director of Contracting and Provider Engagement, he/she performs all critical functions necessary to assess, develop, maintain and/or improve provider network adequacy and performance including leading NH product expansion, recruitment and contracting efforts. The Contract Manager will lead contract language and reimbursement negotiations with a variety of provider entities across New Hampshire and will ensure contract terms and conditions comply with financial and legal requirements of Plan and its regulatory entities. Must-Haves:
3-4 years of progressive provider network & provider network contracting experience.
In-depth knowledge and understanding of contract finance and provider reimbursement methodologies, including risk, shared savings, pay-for-performance and other financial incentive strategies.
Proven negotiation & communication skills with hospitals, Integrated Delivery Networks, physicians and ancillary service providers.
Knowledge of federal and state Medicare, Medicaid, and relevant guidelines, regulations and standards.
Previous healthcare industry experience.
Nice-To-Haves:
IDEALLY WILL LIVE IN NH or at minimum in drivable distance to Manchester, NH, (MA, southern Maine will be considered)
Key Functions/Responsibilities:
Assists our provider partners in the interpretation of data tools and analytics provided by the Plan, including Alternative Payment Arrangements (APMs) and Quality Incentive Programs (QIPs) reporting and other incentive programs developed.
Ensures the contracting and implementation process is administered appropriately and ensures integrity of data. Ensures materials used with providers are accurate and appropriate for the given situation.
Demonstrates knowledge of varying payment methodologies including but not limited to DRG, Capitation, APMs, Fee-for-Service, Per Diem, Per Case and Percent of Charges.
Supports strategic network composition and design initiatives, consistent with the objectives of Well Sense.
Leads and manages all aspects of provider implementation to ensure provider hierarchy and data are loaded appropriately in all relevant systems. This includes understanding and communicating unique arrangements and ensuring the Plan accurately administers those arrangements.
Ensures provider compliance with contractual, regulatory and NCQA requirements and standards.
Participates in cross-functional workgroups as requested.
Gathers and analyzes data and other relevant intelligence in assessing provider network adequacy against required standards and business expectations;
Identifies, assesses and develops strategies for improving provider and network cost, utilization and quality performance;
Leads negotiations of financial and other contractual terms in all lines of business;
Ensures all contract terms and conditions comply with financial and legal requirements of Well Sense and its regulatory entities (e.g., NH DHHS, Medicare, DOI etc);
Develops and maintains business relationships with high-level representatives of key contracting hospitals, physicians and ancillary service providers;
Participates in the development, implementation & continuous improvement of departmental policies, procedures, workflows, and tools as they relate to network development and provider contracting;
Performs other duties as required to accomplish departmental and corporate goals & objectives.
Qualifications: Education:
Bachelor's Degree in Health Care Administration, Business, related field, or an equivalent combination of education, training and experience is required.
Required Experience:
3 years of progressive experience in a contracting and analytical capacity in a leadership role is required for individuals with a baccalaureate degree, four years' experience is required for individuals without a baccalaureate degree.
Competencies, Skills, and Attributes:
Proven analytical skill in assessing and projecting financial, utilization and quality performance on an individual provider and network basis;
In-depth knowledge and understanding of contract finance and provider reimbursement methodologies, including risk, shared savings, pay-for-performance and other financial incentive strategies;
In-depth knowledge and understanding of current healthcare industry issues and trends, including national and state-level payment reform landscape and strategy (e.g., accountable care and patient centered medical home);
Proven negotiation skills with hospitals, Integrated Delivery Networks, physicians and ancillary service providers;
Proven skill in critical thinking and strategic planning and implementation;
Knowledge of federal and state Medicare, Medicaid, and relevant guidelines, regulations and standards.
Effective communication (verbal and written) and relationship building skills;
Expertise in Microsoft Office programs and industry-standard financial applications as appropriate.
