To coordinate and negotiate hospital, physician, (IPAs, PPMs, individual providers, multi-specialty groups) and ancillary service agreements that are in accordance with Health Plan and State guidelines.
- Requires in-depth professional knowledge and practical/applied expertise in own discipline and basic knowledge of related disciplines within the broader professional field
- Has knowledge of best practices and how own area integrates with others; demonstrates awareness of the industry, including regulatory, evolving customer demands, and the factors that differentiate the organization in the market
- Acts as a resource for colleagues with less experience; may lead projects with manageable risks and resource requirements
- Solves complex problems and takes a new perspective on existing solutions; exercises judgment based on the analysis of multiple sources of information
- Impacts a range of customer, operational, project or service activities within own team and other related teams; works within broad guidelines and policies
- Works independently, receives minimal guidance
- Explains difficult or sensitive information; works to build consensus
JOB SPECIFIC RESPONSIBILITIES:
- Assist with the development and execution of a provider network recruitment plan for Dallas SDA.
- Lead assigned negotiations (i.e., hospital, physician and ancillary) and ensure the negotiations result in the unit cost targets expected and meet the objectives of the health Plan and comply with the State's reimbursement to the provider.
- Facilitate and provide oversight to the provider set-up and contract configuration to ensure accurate claims adjudication.
- Evaluate and monitor providers' performance standards and financial performance of contracts.
- Assist with and track credentialing and termination activities.
- Coordinate with internal departments and contracted providers to implement and maintain contract compliance.
- Anticipate customer needs to proactively develop solutions to meet them.
- Serve as a key resource on complex issues.
- Coordinate with Provider Services to create innovative solutions to provider contract related issues.
- Participates in problem solving with providers. Shares provider feedback to other departments on problems encountered. Identifies trends and recommends remedial action.
- Participates in provider access studies and creates provider access study reports.
- Assure that all providers understand the Plan's policies, procedures and contractual obligations.
- Bachelor's degree in healthcare administration, business administration, marketing, related field or equivalent experience. Required.
- At least two years of contracting experience in a healthcare and/or managed care environment. Required.
- Experience with complex payment strategies. Preferred.
- In depth knowledge of Medicaid payment methodologies. Preferred.
- Proficient in the use of Microsoft Office products to include Outlook, Word, Excel and PowerPoint. Required.
- Excellent problem solving skills and the ability to multi-task. Required.
Minimum Formal Education:
Four-year Bachelor's degree or equivalent experience required.
Specific Knowledge, Skills and Abilities:
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self-impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message