Duration: 12 Months Contract – To – Hire
Location: Harrisburg / Pittsburgh PA
Job Description:
• Responsible for development and management of provider networks for all products: Medicaid, and Medicare.
• Responsible for hospital and physician network development and management.
• Develops and recommends policy changes related to provider recruitment and contracting.
• Recruits and negotiates contracts with specific providers within operational and potential new counties to meet company requirements.
• Oversees training and communication for network providers and acts as a liaison with the provider community.
• Ensures compliance with pricing guidelines established by AMFC and Plan.
• Ensures provider contracting is consistent with claim payment methodologies.
• Maintains familiarity with Medicare and State Medicaid fee schedules and reimbursement methodologies and analyzes comparable Plan pricing guidelines.
• Resolves difficult complex contract issues to ensure that provider contracts are in compliance with state, federal, national accrediting agencies and Plan contracting guidelines.
• Ensures that non-standard contract elements are communicated to appropriate departments and obtains AMFC and Plan approval prior to submission to provider.
• Responsible for the accuracy and timely management of all provider contracts.
• Responsible for implementation of electronic strategies for provider network to include increasing electronic claims submission and implementation of improved processes that result in increased auto-adjudication of claims.
• Responsible for achievement of quality and health plan objectives through accomplishment of provider initiatives