Provider Contract Specialist

Provider Contract Specialist

Perform a variety of technical tasks related to the planning, development, negotiation, coordination, and monitoring of HPSM provider contract activities; make program-related decisions; ensure contracts meet regulatory criteria; and establish basic program policies and coordinate functions with other HPSM departments.

Position overview

Essential Functions:

• Act as primary point of contact for provider contracts and MOUs/LOAs interpretation, and provider dispute as related to contractual agreements. This will include supporting the process improvement effort and assisting in resolving complex payment issues.
• Draft and review provider contract templates as well as MOUs/LOAs to ensure regulatory requirements are met.
• Support the negotiation and implementation of provider contracts as well as MOUs/LOAs.
• Support provider outreach to non-contracted providers who have frequent LOAs with HPSM, to initiate contracting.
• Collaborate with business owners to develop provider contracts and/ or MOU/LOAs.
• Support the maintenance of all provider contract templates, MOUs/LOAs and contracting review process including contract renewals, amendments, and terminations.
• Provide recommendations on improving provider contract management systems and implement improvements to existing contract management systems.
• Propose contract revisions to mitigate risks and improve the clarity of contract requirements.
• Work collaboratively with departmental staff and other agencies/participants involved in the contract development and approval process.
• Serve as department resource on the development and implementation of relevant document management systems including a provider contract database; ensure that the database is maintained and updated with ongoing improvements.
• Support internal and external stakeholder meetings related to provider contract language, provider payment, and other regulatory requirements.
• Support audit activities and regulatory reports for NCQA, DMHC, DHCS, and CMS as needed.

Secondary Functions:

• Collaborate with other departments on projects requiring provider contracting expertise as needed.
• Perform other duties as assigned.

Requirements

These are the qualifications typically needed to succeed in this position. However, you don’t need to meet every requirement to apply. 

Education and experience

• Bachelor's degree in business, healthcare policy/administration, or a related field.
• Minimum of two (2) years’ experience in health care or health insurance contract coordination.
• Experience developing provider contract strategies based on cost-benefit analysis, research, and competitive analysis.

Knowledge of:

• Strong knowledge of Medicare and Medicaid markets including regulations and requirements. Includes knowledge of Managed Medicare and Managed Medicaid.
• Strong knowledge of health plan payment, as well as provider billing and payment processes.
• In-depth knowledge of Medicaid and Medicare reimbursement methodologies, fee schedule development, utilizing financial models and analysis in developing provider payment rates and risk-sharing arrangements, and knowledge of claims processing systems and other health plan managed care systems.
• Personal computers and proficiency in Microsoft Office Suite applications, including Outlook, Word, Excel, Access and PowerPoint, and other CRM tools.

Ability to:

• Work cooperatively with others.
• Communicate effectively, both verbally and in writing.
• Adapt to changes in requirements/priorities for daily and specialized tasks.
• Communicate, interact, and collaborate effectively with both internal and external customers.
• Analyze issues and make appropriate decisions.
• Perform work with meticulous attention to detail.
• Organize and prioritize tasks and deliver results within set deadlines.
• Learn how to use new applications and information systems as needed.

Salary and benefits

The starting salary range:  $83,855 - $107,714 annually, depending on the candidate’s work experience.

Excellent benefits package includes:

• HPSM-paid premiums for employee’s medical, dental and vision coverage (employee pays 10% of each dependent’s premiums)
• Fully paid life, AD&D and LTD insurance
• Retirement plan (HPSM contributes equivalent of 10% of annual compensation)
• 12 paid holidays a year, 12 paid sick days a year and paid vacation starting at 16 days a year
• Tuition reimbursement plan
• Employee wellness program

It is HPSM's policy to provide equal employment opportunities for all applicants and employees.  HPSM does not unlawfully discriminate based on race, religion, color, national origin, ancestry, physical disability, mental disability, medical condition, marital status, sex, age, sexual orientation, veteran status, registered domestic partner status, genetic information, gender, gender identity, gender expression, or any other characteristic protected by applicable federal, state, or local law.  HPSM also prohibits discrimination based on the perception that an applicant or employee has any of those characteristics or is associated with a person who has or is perceived to have any of those characteristics.