Under the direction of the Manager of Ancillary Services, the Ancillary Services Contractor develops and maintains an Ancillary provider network that ensures Healthfirst members have superior access to the highest quality by focusing efforts on lowering claims costs, improving the quality of care, and increasing member and provider network satisfaction.The individual must possess experience working in a managed care setting with specific background in network development, provider recruitment, provider outreach, claim resolution, provider education and contract negotiations. Works with multiple provider types, e.g. physician, ancillary, medical groups, behavioral health or hospitals to supports a full range of contract arrangements and pricing mechanisms.
- Monitor and audit contracted ancillary providers to ensure that accurate demographic, payment and fee schedules are loaded into the HF Provider System correctly.
- Manage a network of Ancillary Providers for all lines of Healthfirst's business (such as Medicaid, CHP, Medicare, and Commercial).
- Resolve configuration issues by identifying root causes in order to prevent claims denials and to ensure claims are paid correctly.
- Facilitate meetings cross-departmentally to achieve positive outcomes in management of ancillary provider network.
- Create contracts in HF contract software and review credentialing documents submitted by Provider/facility via Universal Credentialing Data Source, The Council for Affordable Quality Healthcare (CAQH) or PDF application to ensure that all the required credentials are included and that valid documents for behavioral Providers and facilities are provided
- Negotiate and execute Single Patient Agreements for Out Of Network (OON) Providers in order to determine the Provider's payment arrangement.
- Individual should be familiar with contracting and reimbursement methodologies for ancillary services providers.
- Educate newly credentialed Providers on Healthfirst's policies and procedures such as billing and authorization requirements, utilization of Healthfirst's Provider portal, claims submission, etc., via various methods (telephonic, face-to-face, webinar, etc.).
- Analyze provider network based on monthly report to ensure that Plan is meeting Health Plan Network (HPN) State requirements.
- The individual would work closely with Network Management, Credentialing, and the business analytics unit within the Ancillary department, to complete the analysis.
- Identify root cause of claims issues and facilitate resolution by working closely with Reimbursement and Claims departments. Clearly communicate resolutions and progress to the Providers.
- Assist Appeals and Grievances (A&G) department by acting as liaison between Providers and A&G department to achieve favorable outcomes of member related issues, complaints, balance billing and other issues.
- Ensure that all Providers' inquiries received via email and phone call are addressed efficiently and effectively within required time-frame.
- Assist management with research and facilitation of projects related to contract updates, new product implementation and new reimbursement methodologies.
- Additional duties as assigned
Minimum Requirements:
- Experience managing or performing high level servicing to a portfolio of customers/providers
- Contracting experience - Ability to work independently in dynamic environment
- Ability to take initiative and work independently
- Ability to prioritize and multi-task
- Strong customer-centric and analytical skills
- Strong sense of urgency and self-motivational qualities
- Excellent oral and written communication skills
- High School Diploma or GED
Hiring Range*:
- Greater New York City Area (NY, NJ, CT residents): $68,900 - $99,620
- All Other Locations (within approved locations): $61,300 - $91,120
As a candidate for this position, your salary and related elements of compensation will be contingent upon your work experience, education, licenses and certifications, and any other factors Healthfirst deems pertinent to the hiring decision.
In addition to your salary, Healthfirst offers employees a full range of benefits such as, medical, dental and vision coverage, incentive and recognition programs, life insurance, and 401k contributions (all benefits are subject to eligibility requirements). Healthfirst believes in providing a competitive compensation and benefits package wherever its employees work and live.
*The hiring range is defined as the lowest and highest salaries that Healthfirst in "good faith" would pay to a new hire, or for a job promotion, or transfer into this role.
