Contracting Specialist

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Plays a critical role in developing a network for our members and providers. Reporting to the Manager of Contracting you will be a critical part of the Provider Relations team.

The ideal candidate for this role is a passionate, community oriented and has direct health plan managed care contracting experience. You have strength in negotiating complex contacts, evaluating competing priorities while staying aligned with organizational goals and strategies. You are technically savvy with a solid understanding of network adequacy requirements and health plan analytics to aid in the contracting process. You are flexible and thrive in a fast-paced, environment.

The Contracting Specialist is responsible for analyzing contracts between Peak Health and its network providers for the various Peak Health products. Analyze data from various sources and systems for both physician and hospital services in order to present reports to key management and staff and to recommend and implement solutions to assist in the contracting decision-making process.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in Business Administration, Health Care Management OR High School Diploma and equivalent work experience.

EXPERIENCE:

1. One (1) year of work experience in healthcare data analytics, healthcare consulting analytics or healthcare contracting analytics.

2. One (1) year of related healthcare insurance experience in related contractual, financial or provider related activities with major healthcare insurance companies.

 

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Direct experience in data analysis, financial analysis and reporting to include proficient extracting information from various payer systems; utilizing information obtained in most applicable manner; and developing complex mathematical models

2. Progressive experience in health care management, physician groups, hospitals, payer contract negotiations, legal reviews of contract, or contact management preferred.

3. Consulting and/or healthcare decision support work experience in the healthcare industry preferred.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

 

1. Conducts negotiations with hospitals, physicians and ancillary providers on behalf of Peak Health.

2. Presents healthcare data in a meaningful, concise and beneficial manner to upper management.

3. Utilizes data to provide consulting service and decision support on healthcare topics critical to health plan system wide decisions for upper management.

4. Develops and maintains tracking system for reimbursement and statistical information.  Ensures data integrity and accuracy.

5. Summarizes offers for review with appropriate Peak Health committees and individuals.

6. Communicates the implementation of new and renewal contracts to upper management and monitors the reimbursement to ensure accurate payment of claims by Peak Health.

7. Audits large volumes of data and conducts in-depth quantitative analysis of results and evaluates trends.

8. Communicates and educates other regarding financial improvement analysis, findings and recommendations.

9. Maintains contract files for Peak Health.

10. Maintains physician fee and hospital rate information for Peak Health contracted providers.

11. Maintains contract information on major providers with selected competitor and benchmark providers.

12. Organizes meeting materials and attends various organization meetings as needed as well as assists in development of annual strategic planning.

13. Works with providers to resolve provider billing, denial, and appeal issues and explores hassle reduction improvements to incorporate into new and existing contracts.

14. Must remain current with how information is collected, maintained and reported in all key systems.

15. Participates in meeting the objectives of the work unit and goal of the department.

 

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

 

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1. Standard office environment.

 

SKILLS AND ABILITIES:

1. Thorough understanding of healthcare regulations.

2. Ability to perform contract modeling.

3. Understanding of healthcare reimbursement payment methodologies. 

4. Strong problem solving and quantitative abilities.

5. Excellent communication and collaboration skills.

6.Attention to detail.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2901 PHH Provider Management