JOB SUMMARY
Provider Contracting Specialist is a specialized healthcare professional who negotiates, implements, and manages the full contract lifecycle between healthcare providers and the Plan. This role ensures all agreements meet TRICARE regulations and URAC standards. Ensures providers understand Plan policies and contractual requirements. Develop and maintain positive working relationships with participating providers. Conduct analysis of business need and maintain a comprehensive network; collaborates with utilization management, marketing, member services and credentialing.
RESPONSIBILITIES
- Review, analyze, negotiate, implement, and maintain existing contracts with an understanding of professional rate schedules and contractual language
- Identify network development opportunities through financial analysis, client requests, and product development
- Define performance improvement opportunities
- Assist with initial applications for completeness, timeliness, and accuracy in accordance with established guidelines
- Assist with provider orientation and training
- Facilitate interdepartmental collaboration to resolve complex provider issues related to contracting and contract configuration
- Provides general instruction and support on USFHP products, provider manual, provider directory, Plan policies and procedures
- Research, resolve, and respond to provider/ancillary provider inquiries including, but not limited to, participation requirements, credentialing requirements, credentialing status, contract terms, fee schedules, reimbursement, utilization, access/availability standards, member eligibility, consult report requirements, etc.
- Document and track inquiries received and resolution
- Monitor contract performance through claims and data analysis
- All other duties as assigned by management
YEARS OF EXPERIENCE
- 3-5 years’ experience in a provider contracting role; experience with hospital or large network contracting a plus
- 2- 3 years’ experience working with mental and physical medicine providers including medical groups, health systems, ancillary providers, and allied health professionals.
TECHNICAL SKILLS/COMPETENCIES
- Familiar with various reimbursement models including DRG, fee for service, bundle payments, etc.
- Industry payment rules, billing, coding, etc.
- Proficiency in Microsoft Office: Word, Excel, PowerPoint, and Access
- Must be organized and detail oriented.
- Ability to meet stringent deadlines and adjust priorities with business needs
- Excellent communication & analytical skills.
- Experience with SalesForce & Conduent a plus
EDUCATION/CERTIFICATION/LICENSE
SALARY RANGE: $85,000.00-$90,000.00
Benefits Statement:
SVCMC, Inc. provides a robust benefits package that includes medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services. Employees also receive vision coverage through UnitedHealthcare Vision and dental benefits through MetLife. Basic life and disability insurance are automatically provided at no cost. All employees are eligible for commuter benefits, tuition reimbursement, and a 401(k)retirement plan with an immediate employer match that is fully vested from day one. SVCMC also offers a generous time off package, which includes vacation, 10 paid holidays, and 3 personal days. Additionally, employees have access to a comprehensive Employee Assistance Program and exclusive discounts through Working Advantage.
SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER – ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.
HYBRID Work Schedule:
Mondays & Fridays Remote. Tuesdays through Thursdays in office. 8:30 am - 4:30 pm