Provider Contract Specialist
Company: Point32Health
Location: East Providence
Posted on: June 24, 2022
Job Description:
Under the direction of the Manager, Provider Network Management,
the Contract Specialist combines in depth business knowledge,
technical and analytic skills as well as financial skills to ensure
all aspects of a contract are implemented and managed throughout
the life of the contract. The Contract Specialist serves as THP's
liaison with the provider community as it relates to the
interpretation of contract language, financial, and operational
aspects of the contract.*Please note - this position is remote at
this time with the possibility of a Hybrid work model in the future
at the Canton, MA office.*Job DescriptionKEY
RESPONSIBILITIESEssential functions detailed below occur
simultaneously, therefore, the employee must be able to
appropriately handle each essential function, prioritize them and
seek assistance when necessary. These functions need to be
performed on a consistent and regular basis, using good judgment.
Ability to learn and apply Tufts policies consistently and seek out
guidance when necessary is required.Contract Management and
Implementation:
- Serve as a knowledgeable resource on new and current provider
contracts.
- May be involved in negotiating the intent of contract
language.
- Analyze and interpret contractual, legal, regulatory and
legislative provisions to ensure contracts meet business and
regulatory compliance. Develop alternative approaches when
appropriate.
- Review proposed contracts and make recommendations based on
solid knowledge of reimbursement methodologies, and system and
operation constraints.
- May negotiate with providers alternative methods of
implementation that supports the intent of already agreed upon
terms or rates (e.g., crosswalking Medicare DRGs to All Payor (AP)
DRGs).
- Ensure contract terms are loaded correctly in the appropriate
THP systems.
- Interpret reimbursement methods.
- Collaborate with other departments as well as within own
department to research and resolve contractual issues.Financial and
Analytical Related Responsibilities:
- Prepare detailed financial analysis using data from multiple
resources as needed in support of the contract management to value
the financial terms outlined in the contract.
- Synthesize information from multiple sources (i.e.,
project-specific results, standardized reports, other project
findings, and current business initiatives) to understand and
interpret findings relative to business needs and objectives.
- Analyze, research and interpret results, variances and
trends.
- Prepare and communicate analysis and recommendations verbally
and in writing to provider network and THP management.
- Research data anomalies and work with appropriate technical
and/or business departments to ensure integrity and quality of
data.Provider Network Relationship Building and Management:Serve as
THPs Liaison with the provider network community as it relates to
contract maintenance and management, operational, and
implementation issues.Serve as a contact for IPA and/or Hospital
Leadership for:
- Financial analysis and/or issues
- Operational issues
- Data and/or Bulletin Board issues (Electronic Data
Downloads)
- Reporting/Web ReportingMay serve as a resource for network
contacts to provide ongoing consultation and coaching, with a focus
on action plan development and monitoring, drill down analysis, and
bulletin board training.In collaboration with Clinical
Services/Medical Management respond to questions (e.g., UM
programs, prior authorization requirements).RequirementsEDUCATION
- B.S./B.A. degree requiredEXPERIENCEThis position requires a
minimum of 3-5 years work experience. Advanced financial analytic
abilities are required. Proficiency in the use of PC based
computers is essential. Previous experience in a managed care
setting is strongly preferred. The position requires knowledge of
provider reimbursement terms which include fee-for-service, RBRVS,
per diems, DRGs, OPPS, carve-outs, etc.Must be a self-starter with
the ability to identify, understand, research, and solve unique and
complicated financial and operational provider issues as it relates
to their specific contracts. Must have the ability to work
independently on customized, developmental and highly complex
projects requiring a high degree of conceptual, analytical and
technical skill. Must recognize and take into account the broader
business, operational and financial impact of focused,
department-specific initiatives, analytic questions and/or
decisions. Requires a high level of problem solving ability,
initiative and judgment. Requires the ability to work in a fast
paced environment balancing multiple priorities and utilizing
resources aggressively. Requires excellent interpersonal skills to
work with a diversity of individuals from numerous departments and
different levels within and outside of the organization. Requires
excellent oral and written communication skills and presentation
skills Must be able to work cooperatively as a team member. Regular
interface with various levels of Tufts leadership, staff, providers
and Provider Leaderships is required as well. Unlimited access to
confidential member and provider specific data. Fast paced office
environment handling multiple demands. Must be able to exercise
appropriate judgment as necessary.What we build together changes
our customer's health for the better. We are looking for talented
and innovative people to join our team. Come join us!Please note:
As of January 18, 2022, all employees including remote employees
must be fully vaccinated. This position will require the successful
candidate to show proof of full vaccination against COVID-19.
Point32Health is an equal opportunity employer, and will consider
reasonable accommodation to those individuals who are unable to be
vaccinated consistent with federal, state, and local law.About
Us:Point32Health is a leading health and wellbeing organization,
delivering an ever-better health care experience to everyone in our
communities. Building on the quality, nonprofit heritage of our
founding organizations, Tufts Health Plan and Harvard Pilgrim
Health Care, we leverage our experience and expertise to help
people find their version of healthier living through a broad range
of health plans and tools that make navigating health and wellbeing
easier.At Point32Health, were working to reshape the world of
health care by pushing past the status quo and delivering even more
to the diverse communities we serve: more innovation, more access,
more support, and healthier lives. And we want people like you on
our side to make it even better.This job has been posted by
TalentBoost on behalf of Point32Health. TalentBoost is committed to
the fundamental principle of equal opportunity and equal treatment
for every prospective and current employee. It is the policy of
TalentBoost not to discriminate based on race, color, national or
ethnic origin, ancestry, age, religion, creed, disability, sex and
gender, sexual orientation, gender identity and/or expression,
military or veteran status, or any other characteristic protected
under applicable federal, state or local law.Req ID:
R2965#TalentBoostPoint32Health
Keywords: Point32Health, East Providence , Provider Contract Specialist, Other , East Providence, Rhode Island
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