Provider Contract Specialist

Company: Point32Health
Location: Reading
Posted on: June 12, 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, Somerville , Provider Contract Specialist, Other , Reading, Massachusetts