Position Purpose

This position provides day to day management and analysis of provider contracts and negotiations. This includes timely and accurate response to all provider contract requests and/or concerns.

The incumbent is also primarily responsible for outreach and education of contracted providers and staff in regards to Hometown Health policies and procedures.

Nature and Scope

The Contracting Provider Specialist will have the responsibility of the relationship between Hometown Health and contracted provider offices and facilities. This will include many of the following responsibilities:

1. Monitoring Network Adequacy requirements.

2. Processing provider requests to join the network.

3. Managing provider additions, terminations, and demographic changes to ensure provider directory accuracy.

4. Negotiating Letters of Agreement for services that cannot be provided by a contracted provider including expedited requests.

5. Have a good understanding of healthcare contracting and be seen as the go-to representative for our contracted providers and their staff.

6. Develop and manage provider relationships demonstrating a customer service approach while adhering to Hometown Health and Renown Health policies and procedures.

7. Identifies/researches and resolves issues including claims, fee schedules, and reconsiderations.

8. Assists in process improvement based on feedback from providers to enhance the quality of care of Hometown Health members and the customer service level of the provider.

9. Analyzing provider contract rate proposals and requests for renegotiation against market standard and presents recommendations to department and Senior Leadership for decision.

10. Manages the Administrative Guidelines and updates as necessary.

11. Possess functional knowledge of medical coding in regards to the contract requirements.

12. Stays current on all accreditation, state, and federal regulations in regards to contracting and network management.

13. Manages regulatory reporting requirements.

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications
Requirements - Required and/or Preferred

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. A Bachelors Degree in a business related field is preferred.

Experience:

Three years in a health care environment with at least three years in contracting required. Provider and/or health plan contracting preferred. Two years contract rate analysis experience required.

License(s):

None

Certification(s):

None

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.