Manages and conducts specific functions of the contracting and provider relations process. This includes sourcing of providers, the RFP process, contract negotiation, problem-solving, measuring - monitoring - and reporting on the status of contract agreements and relationships. A significant focus includes the collection and analysis of cost and competitive data for the development of contracting strategies.
Contract Negotiation: Negotiates less complex financially competitive and predictable contracts or participates in the negotiation of contracts under the leadership of more senior contract managers. Evaluates multiple suppliers through a pre-screening process to evaluate a suppliers' opportunity to provide the best quality, price and service, including reviews of supplier dependability and financial solvency. As a result of the pre-screening process, may eliminate potential suppliers from consideration and further contract negotiations.
As part of contract negotiations, determines quality standards to be included in contracts, develops appropriate metrics, and plans for ensuring quality standards are met over the life of the contract. Prepares a business profile for each potential supplier. The profile indicates the solvency and credit-worthiness of the supplier and to check for any potential problems in the supply chain. This profile is to include: A favorable review of the List Validation and reporting (LVAR) report. A favorable Dunn & Bradstreet Report. Evidence of a robust Quality Program. A review of the Professional Liability and General Liability and Property Damage Insurance minimum limits of $1 million per occurrence, $3 million aggregate (or state regulated limits). Current Licensure, Accreditation and/or Certification.
Servicing Regional Stake Holders: Responsible for communications, assessments, identifying network needs, financial, implementation, forecasting, etc. Evaluates regional stake holder business needs, and selects, from multiple approaches, the appropriate consultative approach to ensure successful interactions and outcomes. Evaluates regional stake holder business needs, and selects, from multiple approaches, the appropriate consultative approach to ensure successful interactions and outcomes. Responsible for employing account management and customer relationship concepts and techniques to ensure service excellence.
Collaboration & Coordination with Provider Relations: This includes provider implementation, communications (provider manual, community provider portal, etc.) maintenance of provider contract files (paper & web), provider data base, provider training, and system configuration quality control.
Network Monitoring: Responsible for generating or coordinating the development of metrics, including financial analysis, supplier oversight, network adequacy (accessibility & capacity), member satisfaction, supplier integrity, business continuity, product recall, etc. Oversees development of suppliers' corrective action plans and ensures submitted plans meet quality and business process standards. Accountable for ensuring suppliers/suppliers are responsive to quality and service level concerns and influencing stakeholders to ensure that interventions are timely and effective.
Regulatory Compliance: Ensures regulatory and statutory compliance of provider contracts and executes on remediation efforts as determined by senior contract managers and leadership. Accountable for ensuring supplier/suppliers are educated on and adhering to the KP Supplier Integrity program. Responds to audit requests for both internal and external audits and develops corrective actions plans, as appropriate.
ExperienceMinimum two (2) years of managed care provider contracting or provider relations experience.
EducationBachelor's degree, OR four (4) years of experience in a directly related field.High School Diploma or General Education Development (GED) required.
License, Certification, RegistrationN/A
Additional Requirements:MS Word, Excel, Access, Visio & PowerPoint. Some knowledge of provider contracting policies, practices and systems.Intermediate understanding and broad application of principles, theories, concepts, practices, and standards in contract negotiation strategies and techniques. Intermediate knowledge of health care industry content practices.Must be able to work in a Labor/Management Partnership environment.
Preferred Qualifications:Minimum two (2) years of managed care provider contracting, or provider relations management experience preferred. Minimum one (1) year of health plan operations cross-functional experience (i.e., claims, customer service, quality & utilization management) preferred.Minimum three (3) years of experience in healthcare industry. Network Management experience. Preferred Provider Organization (PPO) or Point of Service (POS) experience. Healthcare Insurance experience. Experience with creating and conducting trainings. Experience in presenting to senior leadership. Experience in creating, auditing, and editing policies and procedures. Excellent verbal and written communication skills.