Role Overview

Lead/support the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospital, and ancillary facilities across the payment spectrum for HCS’ workers compensation/PIP network.
Lead/support complex negotiations and/or contracting arrangements which require developing a sound business strategy for the financial and legal terms required for contracting initiatives.
Responsible to work with Senior Leadership and Data Analytics to draft provider rate proposals that adhere to HCS’s unit cost guidelines and negotiate such proposals with hospital executives, physicians and ancillary providers directly.
Contributes to drafting hospital, professional and ancillary contract terms to ensure they conform with all regulatory, accreditation and business requirements while advancing HCS’s strategic and business objectives.
This manager should have a demonstrated track record of creating, developing, and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers.
This manager will lead a team of specialists, and independent contributors.
Manage and negotiate contracts in compliance with HCS reimbursement standards.
Assist and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider database maintenance requests, and new hospital implementation.
Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies.
Manages the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the HCS systems.
Collaborates with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and business requirements.
Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business.
Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, and contract storage.
Manages the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.
Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
Collaborate across departments to ensure that provider services are aligned with the needs of claimants and the organization.
Assist with keeping the provider network integrated with the organization’s objectives.
Provide management level leadership and support all of the contracting staff.
Assist the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
Represent the organization at industry conferences, webinars, and other events.

Requirements

High School Diploma/GED required.
Bachelor degree preferred or relevant experience in lieu of degree in health or health care related field from an accredited college or university or relevant experience.
Requires a minimum of 5 years demonstrated business experience in hospital and provider group finance and/or managed care network development.
Requires a minimum of 5 years in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Workers Compensation/PIP pricing, and incentive arrangements.
Requires a minimum of 5 years prior provider experience in a healthcare setting including but not limited to Workers Compensation, PIP, Commercial, Medicare, Medicaid, and/or Value Based Programs is required.
Requires a minimum of 3 years’ experience in health care cost data analysis.
Requires a minimum of 3 years supervisory experience and/or leading people by influence.
Demonstrates ability to create, develop, and maintain business relationships.
Proven analytical, business case, and product design skills a must.
Proven ability to exercise sound judgment.
Proven ability to ask probing questions and obtain thorough and relevant information.
Must be detail oriented with strong organizational skills.
Proven ability to follow detailed instructions is essential, along with proven problem-solving skills.
Demonstrates flexibility and adapts to multiple responsibilities encompassing multiple areas within the organization.
Must demonstrate the ability to effectively present information and respond to questions from groups of managers, and clients.
Must have effective verbal and written communication skills and demonstrate the ability to work well within a team.

Benefits

Requires moderate travel up to 30%.

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