Provider Contracts Specialist

Sanford Health•Marshfield, WI

2d•$24 - $39•Remote

About The Position

Provider Contract Specialist (PCS) is responsible for maintaining, coordinating the process of, and establishing pricing arrangements involving provider groups, facilities and ancillary entities joining the Health Plan networks, including creating standard contracts for providers across the Health Plan service area. The PCS has an integral role in building and maintaining high value and compliant networks which may involve provider recruitment activities. Works directly with chain of command to develop and implement contracting strategy with various types of providers/facilities across the Health Plan service area. Evaluates and negotiates physician, ancillary and hospital contracts, including contract language and reimbursement methodologies for fee for service arrangements. Prepares standard accurate agreements to formalize such arrangements. Ability to identify data needed to evaluate and develop network reimbursement proposals to develop arrangements advantageous to our members and Health Plan. Calls upon team analysts for support. Works directly with team analysts and other department managers to understand how the negotiated agreement is translated into the company's systems. Prepares timely and accurate communications to other departments for loading finalized agreements into production. Assists with internal audit of provider records to ensure accurate reimbursement. Serve as liaison to other departments on contract and reimbursement interpretation issues and ensures timely turnaround. Must have strong knowledge of the Health Plan's end-to-end provider engagement processes, including interdepartmental handoffs as well as plan policies and procedures to ensure the best possible provider experience. Manage or participate in project work as assigned. May be called upon to assist in network education, onboarding and overall network relationship building.

Requirements

Bachelor’s degree or equivalent experience preferred in the areas of finance, business, health care administration or communications preferred but willing to waive with strong work experience.
Prior experience working with health care insurance or insurance network management, on commercial and/or government network reimbursement methodologies.
Experienced in analyzing, understanding, communicating, and negotiating financial impact of contract terms, payment structures and reimbursement rates with providers.
Proficiency with contract reading and redlining.
Proficiency in MS Office applications.
Ability and willingness for occasional travel, including overnights, which may include holding face to face meetings at the Health Plan offices, provider offices or attending conferences.
Work at Home/Remote Requirements must ensure designated work area is free from distractions during work hours and virtual meetings, and must provide a high-speed DSL or cable modem for a workspace.

Nice To Haves

Previous experience with behavioral health care reimbursement is a plus.

Responsibilities

Maintaining, coordinating the process of, and establishing pricing arrangements involving provider groups, facilities and ancillary entities joining the Health Plan networks
Creating standard contracts for providers across the Health Plan service area
Building and maintaining high value and compliant networks which may involve provider recruitment activities
Developing and implementing contracting strategy with various types of providers/facilities across the Health Plan service area
Evaluating and negotiating physician, ancillary and hospital contracts, including contract language and reimbursement methodologies for fee for service arrangements
Preparing standard accurate agreements to formalize such arrangements
Identifying data needed to evaluate and develop network reimbursement proposals to develop arrangements advantageous to our members and Health Plan
Preparing timely and accurate communications to other departments for loading finalized agreements into production
Assisting with internal audit of provider records to ensure accurate reimbursement
Serving as liaison to other departments on contract and reimbursement interpretation issues and ensures timely turnaround
Managing or participating in project work as assigned
Assisting in network education, onboarding and overall network relationship building