Network Contracting Acct Spec

About the role

This role facilitates and leads negotiations with Horizons network of provider partners of over 32,000 professionals, 1,500 ancillary providers and 76 hospitals in our New Jersey, Pennsylvania and New York markets representing billions in spend. Negotiations include but not limited to Hospitals, Physicians and Ancillary providers, including value based programs for all of Horizons medical lines of business including 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, including collaborating with other departments to assure contract and special arrangements are loaded correctly.
• Initiate and manage provider file maintenance requests, claims stops and new hospital implementation.
• Review technical inefficiencies as it relates to system wide claims, configuration, and provider mapping discrepancies.
• Collaborate with other internal business partners to conduct research, identify root cause analysis and work fall out reports causing operational deficiencies.
• Collaborate with Medical Economics and Actuary to prepare rate proposals for all lines of business.
• Accountable for the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the 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 that the organization could use at industry conferences, webinars and other events.

Qualifications

• High School Diploma/GED required.
• Bachelor degree in business, finance, accounting, health administration preferred or relevant experience in lieu of degree.
• Preferred Master’s degree in health or business.
• Minimum of 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.