Sr Provider Contracting Specialist

Job Description

Job Description

SUMMARY: The Sr Provider Contracting Specialist egotiates and maintains provider contracts including but not limited to: hospital renewals, negotiations, analysis, and day-to-day service issues and operations; ancillary providers; ancillary facilities; individual and small group physicians. Need to understand, negotiate, implement, and support complex value-based provider contracts with key hospital and physician providers. Ability to evaluate different reimbursement methodologies and work with HNE Finance to determine the financial impact of changing reimbursement methodologies with key providers. Assist Provider Appeals in the research and resolution of the hospital and provider appeals, Assist Provider Relations with inquiries and concerns and compliance regarding billing policies and payment rates. Maintain the fee schedule and payment rate library. Assess the financial impact of new provider contracts; analyze the impact of change in existing provider contracts. Ownership of specific Vendor relationships and day-to-day service operations.

ESSENTIAL FUNCTIONS:

Hospital and Provider Hospital Organization (PHO) Providers

• Responsible for negotiating and maintaining both Fee For Service and Value Based contracts for hospitals, physicians, physician groups and PHOs. Needs to understand, work with, and explain to providers all the components of a value based contract that includes financial and quality performance risk consequences for the provider(s)
• Takes the lead on day to day hospital, IPA, PHO, or other Provider organization inquiries and contract changes as they arise in written format, by phone and via the Contracting or PRelations email box. This also includes facilitation and participation in Joint Operation Committee (JOC) meetings, calls and minutes with an assigned provider
• Collaborates with Contracting Director and Manager to develop contracting strategies, including financial models such as physician fixed payment models, inpatient case rate methodologies, surgical and other bundled payment methodologies, and all components of provider risk sharing arrangements, including the interpretation and presentation of provider risk reporting for both cost and quality drivers
• Thorough understanding of Commercial and Government Programs (including but not limited to Medicare Advantage and MassHealth programs) reimbursement and payment methodologies including but not limited to, use of DRGs, RVUs and other fixed payment reimbursement models
• Works with IT Configuration to determine if negotiated payment structure can be supported in HNE’s current Amysis environment
• Coordinates implementation and ongoing management of executed contracts through regular interaction and scheduled Joint Operations Meetings with providers as appropriate

Ancillary Providers and Individual or Small Group Providers

• Negotiates and maintains provider contracts including but not limited to: any type of ancillary providers required by HNE ‘s existing Commercial, Medicare, and Medicaid lines of business and/or any LOBs that HNE may add at any point in the future; ancillary non-acute facilities; individual and small group providers
• Evaluates and monitors provider network adequacy, provider accessibility, and payment rate parity by major provider type
• Makes recommendations for provider network additions/ consolidations/terminations or changes in payment arrangements
• Negotiates contracts in accordance with established HNE parameters and to meet annual budget goals for medical unit cost increases
• Takes the lead on day to day ancillary provider inquiries regarding contract changes as they arise in written format, by phone and via Contracting email box
• Works with IT Configuration to determine if negotiated payment structure can be supported in current version of Amysis and works to find an alternative payment solution if the provider’s requested methodology cannot be supported within the current Amisys environment
• Coordinates implementation and ongoing maintenance of executed contracts
• Develops and maintains new and existing provider and facility fee schedules
• Maintains fee schedule "library" for internal use
• Continued examination of Standard HNE Fee Schedules to determine impact
• Works with Configuration Dept., Finance, and other departments as needed to develop fee schedule samples for internal and external use
• Keeps abreast of all general Healthcare Industry information sources and periodic coding changes implemented by CMS, NCQA, and other outside organizations that would have measurable impact on the operations of providers and /or health plans
• Proposes changes to payment methodologies or operational processes as needed to mitigate any negative effects to HNE of changes initiated by contracted providers, non-contracted providers, or state or federal governments
• In combination with Configuration and other HNE departments as required, coordinates and implements annual and other periodic code additions, deletions and revisions to relevant fee schedules
• Performs various analytic work as needed or in conjunction with other HNE departments. Develop and maintain contract and payment database
• Maintains documentation of HNE payment descriptions for each contracted entity
• Produces reports of historical payments and payment comparisons as needed
• Performs research and analysis in support of verification of HNE systems integrity and provider billing compliance
• In conjunction with Payment Integrity staff and F,W,&A staff within the Compliance area of HNE, provides support in the implementation and post-implementation verification of provider contract configuration and payment accuracy
• Researches and identifies payment discrepancies as a result of HNE system issues and/or provider billing anomalies
• Performs impact analysis of changes to fees and payment methodologies
• Performs impact analysis of changes within a fee schedule
• Performs impact analysis of change to fixed fee schedule methodology from other payment methodology. (i.e. comparison of fixed payments to charge-based payments)
• Performs comparisons between fee schedules and various payment arrangements

Vendor Relationships

• Assumes ownership of assigned provider related vendor contracts and provider related vendor relationships to resolve provider related vendor payment and day-to-day service issues.

Ad hoc Projects

• Assumes ownership of ad hoc projects including but not limited to, develop project summary, determine issues to be resolved and implement necessary changes

MINIMUM REQUIREMENTS:

Bachelor’s degree in Business, Allied Health or related field with 3 or more years of experience in provider contract negotiations in a managed care environment; or an equivalent combination of education and experience. Some experience with value based risk contracting preferred

• Knowledge of multiple provider contracting models and arrangements
• Strong working knowledge of managed care products, policies and procedures
• Strong analytical skills with Excel. Able to manipulate, index, and query data in multiple views and formats
• Effective communication and presentation skills, both written and verbal; skilled at working with providers by telephone conference call
• Strong computer skills including Microsoft Word, Excel, PowerPoint, Access, (Amisys knowledge preferred but not required)
• Initiative, excellent judgment and superior problem solving skills
• Represent HNE and its initiatives in a positive and professional manner
• Strong customer orientation and ability to manage expectations and needs of all customers, both internal and external
• Able to effectively balance multiple priorities
• Ability to maintain poise, composure and diplomacy in negotiations and when under pressure or challenged