Overview

Brief Summary of purpose:

Responsible for the analysis, negotiation/renegotiation, implementation, readjustment, evaluation, and continuous improvement of all functions of provider contracting. Manages financial and operational issues related to contractual provider arrangements. Responds to both internal and external customers regarding provider contractual arrangements, both for contract implementation and ongoing operations.

Responsibilities

Primary Job Responsibilities:

• Negotiates, develops and designs contractual provider (Hospital and physician) arrangements including language and pricing methodologies.
• Evaluates contractual payment methodologies in order to determine financial risk to insurer and provider (per diem, capitation, discount from charge, DRG, case rate, bundled payments, pay for performance programs, etc.). Ensures the design, production, and distribution of site financial, utilization and member information; ensures the production and completeness of annual site settlement reports. Interfaces between the Plan's Finance department and individual sites for budget, financial reporting and settlement arrangements for all relevant products.
• Performs quantitative analyses of various financial and clinical data in order to evaluate multiple contracting options. Reports on performance of ongoing contractual arrangements to appropriate parties.
• Manages, coordinates and resolves operational issues related to specific areas of responsibility. Serves as contact person for internal departments (i.e. Claims, Finance, Care Management Services, Patient Relations, Marketing, Credentialing, Provider Relations, etc.).
• Researches, analyzes and presents recommendations to Manager regarding contractual and financial decisions.
• Manages provider correspondence relating to contracts and responds to requests from potential new providers for FCHP.
• Maintains computerized tracking system for new and revised agreements. Coordinates and communicates contractual information to appropriate departments within FCHP.
• Maintains assigned provider network; physician, hospital, ancillary, and/or carve out vendor as assigned by Director or Manager.
• Prepares, updates and maintains files and database for all assigned provider contracts.
• Serves as committee member in cross-functional teams as assigned by Director or Manager.
• Assists in Provider Relations activities including servicing, educating and distributing information to contracted providers.
• Analyzes and presents financial reports to providers. Makes recommendations to providers regarding quality and cost improvements.
• Other duties as assigned.

Additional Performance Requirements:

• Must be a team player with strong relationship building skills.
• Must be able to prepare and conduct formal presentations to small and large audiences both internally and externally

Qualifications

Education:

Bachelor's degree or equivalent experience required.

Master's degree in Business Administration, Healthcare Administration, or Public Health preferred. Previous background in nursing or any allied health field is often valuable but not required

License/Certifications

Valid Driver's License and Clean Driving Record Required

Experience:

Minimum of three years experience in managed healthcare environment(s) with related work in provider contracting, healthcare finance, provider reporting/profiling, and/or provider relations. Experience in provider contract negotiations, including FFS, capitation models, Hospital contracts and pay for performance models is preferred. Excellent analytical, strategic thinking, and creative thinking skills are required. Superior verbal and written skills, excellent computer skills (Word, Excel, Access) are essential to this position.

Pay Range Disclosure:
In accordance with the Massachusetts Wage Transparency Act, the pay for this position is annually which reflects what we reasonably and in good faith expect to pay at the time of posting. Final compensation will depend on the candidate's experience, skills, and fit with the role's responsibilities.