Position SummaryThis position is remote, but must be located within Ohio or Pennsylvania.
The Senior Network Representative is responsible for contracting, educating, and maintaining provider networks that deliver clinical, financial, and service value to Martin's Point Health Plan members. The Senior Network Representative is responsible for all provider contracting functions in the Health Plan, including but not limited to activities within new and existing market areas and continuously accessing the composition and performance of the provider network. This includes primary care incentive monitoring, comprehensive visit performance, and provider issue management visits. The Senior Network Representative will attend compliance and credentialing site visits to assure we are providing a quality network and meeting HEDIS/NCQA requirements. The Senior Network Representative works closely with the Sales Team to actively recruit new providers to meet or exceed membership growth targets and attends member seminars, charity events, quarterly sales meeting, and other network provider activities.
Job DescriptionKey Outcomes:Network Development- Handles high level contracting and renegotiations with large and strategic provider groups, and PHO's, in all our existing or future markets to ensure complex contractual obligations are being met.
- Leads the contracting effort for opening new expansion markets
- Conducts high level provider education in-services and monitors primary care incentive payment, comprehensive payments, and risk arrangements
- Conducts seminars and trainings with all participating providers to ensure providers are following our payment policies and are in compliance with DOD and CMS requirements
- Responsible for attending Quarterly Health Plan Sales meetings, submits monthly recruitment reports and presents on key recruitment activity
- Responsible for all hospital Capital Requests
- Works closely the Senior Network Operations Specialist and Senior Credentialing Specialist to ensure contracting payments, language, application, and systems are timely and accurately updated
Network Management- Liaison for providers and credentialing to ensure delegated agreements are executed
- Provides training to new staff members acts a role model/coach for new staff
- Assists with high level audit and special contract projects
- Develops our contract and reimbursement manuals to ensure consistency and accuracy
- Communicates with providers regarding substantial changes in benefits or program
- Handles escalated provider issue management cases, payment issues, balance billing cases and providers that are out of compliance.
Education/Experience:- Bachelor's degree or equivalent combination of education and experience
- 5+ years of experience in department provider relations and health care including provider contracting involving physician, facility, and ancillary contracts experience
Required License(s) and/or Certification(s):- Valid driver's license (no restricted or suspended license)
Skills/Knowledge/Competencies (Behaviors):- Significant proven advanced knowledge of managed care contracting and reimbursement methodologies
- Understanding of health plan functions and activities
- Proficiency in Microsoft Word, Excel, and Access Office Products
- Superior communication skills, both verbal and written
- Strong analytical skills to coach employees and providers on benefit and payment polices
- Strong negotiations skills
- Ability to make presentations and represent MPHC externally in public forums
- Strong attention to detail with the ability to organize and execute multiple activities simultaneously
- Problem-solving skills
- Ability to work collaboratively to meet goals
- Ability to work independently
- Ability to travel with potential overnights at least 50% of the time
This position is not eligible for immigration sponsorship.Do you have a question about careers at Martin's Point Health Care? Contact us at:
[email protected] 
