Network Contracting Manager

Responsible for developing, maintaining and supporting the day-to-day contracting and In Servicing processes of the Specialty Provider Networks (SPN) which the respective individual manages for Health Network One, Eye Management, and/or Therapy Network (collaboratively referred to as "HN1").

Essential Functions & Responsibilities

  • Supervise and direct all staff that is assigned to the development and/or expansion strategies for the SPN(s).
  • Manage the prospecting calls to potential providers for inclusion in the targeted SPN, including the continued follow up and documentation.
  • Coordinate the entire contracting process for all potential providers, including prospecting, negotiation, credentialing and orientation.
  • Collect all providers signed contracts, applications and necessary credentialing information, ensuring each State credentialing standard is maintained.
  • Develop, establish and/administer the SPNs until a Network Manager/Director is assigned to assume the Network responsibilities.
  • Execute and support the activities of Network Development for the corresponding SPNs assigned, including: Provider Communications, Provider Outreached, Provider Contracting, Provider Education and Provider Services, among others.
  • Assist contracted providers with access to the Provider Portal. Provide ongoing education on the use and tools of the Provider Portal Provide exceptional customer service to our Provider Network.
  • Complete Provider Maintenance Forms (PMF), when needed, to update Provider changes and or additions in the Network.
  • Develop and maintain a close working relationship with the TPA operations staff and work interdependently with each Department: Claims, Utilization Management, IT, Credentialing and Provider File Maintenance.
  • Advise senior management of both strengths and weaknesses in the SPN and institute or recommend changes which better serve the organization and its assigned membership.
  • Provide education and training to the Provider Representative, Network Manager/Director of the developed SPN.
  • Act as a liaison between HN1 and key and/or high volume Providers with all relevant matters concerning contractual and financial terms as stated in Providers’ contract with HN1.
  • Provide and support network reporting requirements for SPN development and expansions. Maintain oversight and responsibility for all needed internal training and policy implementations.
  • Develop and maintain familiarity with the managed care industry, such as availability of outside sources of information, statutes affecting HN1 business, current industry trends, and general services/locations of major non-contracted health plans and providers.
  • Participate and contribute in all staff and committee meetings as requested by the Regional Network Director, VP of Network Operations, President and/or COO, including evening quarterly Executive Committee Meetings and Medical Advisory Committees (MAC).
  • Support company philosophies, objectives, decisions and policies.
  • Require adherence to department and organizational standards, policies and procedures including HIPAA.
  • Ensure integrity of data entered into Company systems and/or databases.
  • Require traveling more than 75% of the time to the different networks around the Nation.

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Education and/or Experience

  • Bachelor's degree (B.A.) or five (5) or more years of contracting/development experience.
  • Five (5) years of extensive working background in the managed care industry.

Computer Skills

Must have proficiency in Microsoft Office programs, such as, Word, Excel, Access, Publisher and Outlook; internet research; and database programs.

Certificates, Licenses, Registrations

Valid State Drivers License, required.

Other Skills and Abilities

  • Full working knowledge of operations, benefits and systems of HN1 and Health Insurance industry.
  • Strong interpersonal and verbal and written communication skills.
  • Ability to conduct meetings and presentations to health care providers and internal personnel.
  • Knowledge of local medical community.
  • Knowledge of medical terminology, CPT coding, and billing procedures.
  • Strong contracting background.

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