Hosp Contracting Spec II

About the role

This role facilitates and leads negotiations with Horizons network of provider partners, including over 32,000 professionals, 1,500 ancillary providers, and 76 hospitals in New Jersey, Pennsylvania, and New York markets. Negotiations cover various lines of business such as Commercial, Medicare, Medicaid, DSNP, MLTSS, and Casualty services.

Responsibilities

• Facilitate and lead network provider negotiations for Horizons medical lines of business, including Commercial, Medicare, Medicaid, DSNP, MLTSS and Casualty services.
• Accountable for accurate implementation of contracts, collaborating with other departments to assure correct contract and special arrangement loading.
• Initiate and manage provider file maintenance requests, claims stops, and new hospital implementations.
• Review technical inefficiencies related to system-wide claims, configuration, and provider mapping discrepancies.
• Collaborate with other internal business partners to conduct research, identify root cause analysis, and work on fall-out reports causing operational deficiencies.
• Collaborate with Medical Economics and Actuary to prepare rate proposals for all lines of business.
• Interface with matrix partners for network implementation and maintenance of all lines of business, coordinating hospital, ancillary, and professional rate loads, pricing configurations, DRG updates, and contract storage.
• Serve as the go-to person for matrix partners to resolve contract and special arrangement reporting, provider file maintenance requests, claims stops, and new hospital implementations.
• Analyze contracts to identify and implement medical cost savings by introducing innovative industry initiatives and programs.
• Maintain all provider contract language and templates, ensuring they can be configured into core systems.
• Adhere to Horizon standard contract language and payment methodologies.
• Collaborate with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation, and Enterprise requirements.
• Contribute to the development and execution of the network contracting strategy, including methods to adopt value-based contracting for providers operating under fee-for-service models, minimize special arrangements, and align to enterprise affordability objectives.
• Develop and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
• Collaborate across departments to ensure that provider services are aligned with the needs of members and the organization.
• Ensure the provider network is integrated with the organization's objectives.
• Create materials for industry conferences, webinars, and other events.

Requirements

• High School Diploma/GED required.
• Bachelor degree in business, finance, accounting, health administration preferred or relevant experience in lieu of degree.
• Minimum 5 years of business experience in hospital finance and/or managed care network development.
• Minimum 5 years demonstrated experience in two or more with in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Medicare DRG and APC’s, Medicaid pricing, capitation, full risk, shared savings and incentive arrangements.
• Minimum 5 years provider experience in Commercial, Medicare, Medicaid, and Value Based Programs.
• Minimum 5 years’ experience in hospital finance and/or managed care network development.
• Minimum 5 years’ experience in health care cost data analysis and technical document writing.

Qualifications

• Understands the Enterprise Strategic and Financial Plan.
• Understands the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
• Understands Value Based Programs including the financial, quality and operational aspects.
• Proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint).
• Knowledgeable in the use of intranet and internet applications.
• Knowledge of Principals of Health Care contracting.
• Knowledge of health care industry or health insurance industry.
• Knowledge of the hospital and physician communities in the state of New Jersey.
• Knowledge of laws and regulations regulating insurance, HMO hospital and physician practice.
• Knowledge of quality measurement approaches applied in measuring insurance, HMO, hospital and physician practice.

Skills and Abilities

• Demonstrates ability to create, develop, and maintain business relationships.
• Prominent analytical, business case, and product design skills.
• Proven ability to exercise sound judgment.
• Proven ability to ask probing questions and obtain thorough and relevant information.
• Detail-oriented with strong organizational skills.
• Effective verbal and written communication skills.
• Flexible and adaptable to multiple responsibilities encompassing multiple areas within the organization.
• Ability to effectively present information and respond to questions from groups of managers, clients, and customers.