Maintain a high quality, cost effective provider network consistent with the strategy of the service area and the region through negotiating cost-effective, compliant contracts able to be administered by KPMAS' systems. Responsible for interfacing with MAPMG and MSBD to ensure regional strategies, geographic expansion, member satisfaction and product deployments are adequately supported by the provider network.
Essential Functions:
- Successfully negotiate contracts that achieve cost reduction or other contract and relationship maximization. This includes facilities, individual and group practices, using a diverse range of techniques and contracting ''best practices'', to include DRGS, per diems, case rates, and other industry standard payment methodologies.
- Negotiate agreements with hospitals and physician and ancillary providers, including high volume groups, in a manner consistent with market strategy utilizing approved contract templates, approved reimbursement methodologies, KP standards, and applicable regulations.
- Monitor contract performance.
- Work closely with analytics, finance, marketing, claims, UM, member services, membership administration, benefits administration and medical group leadership to implement contracting options on time and within budget.
- Work with Provider Relations to assure smooth transition from contracting to service activities.
- Develop and quantify strategic options for network development and expansion including, but not limited to:
- Identifying contract options.
- Establishing short and long range contractual terms.
- Developing pricing models across multiple facilities, service lines, service levels and programs.
- Maximizing contract leverage.
- Preparing reports on the cost of contracted services.
- Identifying trends and then using a team-based approach to evaluate options for change.
- Work with Legal and Compliance to assure that contract templates are compliant .
- Ensure that contracts can be administered within KPMAS systems.
- Meet all regulations related to their sphere of contracting.
- Coordinate with Practitioner and Provider Quality Assurance (PPQA) to ensure timely credentialing of all providers prior to contract being effective.
- Coordinate with analysts to develop analyses that will result in cost effective contracts.
- Coordinate with Provider Configuration to assure that all contracts are loaded accurately and in a timely manner and to avoid negative impact on claims performance due to retro contracts or inaccurate configuration.
Qualifications:
Basic Qualifications:
- Seven (7) years of progressive responsibility and quantifiable results in network development and delivery system negotiations.
- Five (5) years of experience contracting for multiple managed care products including HMO, PPO, POS, EPO, CDHP and multiple funding options including fully insured and self-funded plans.
- Hospital, physician, and ancillary provider reimbursement methods for commercial and government payers.
- Bachelor's degree required.
- Knowledge of network development, provider network operations, provider relationship management, reimbursement analysis, contract performance analysis required.
- Comprehensive knowledge of Medicare payment methodologies, level of care pricing, and federal and state health care regulations.
- Excellent public presentation, negotiation, stakeholder facilitation, time management, problem solving, analytical, organizational, written, and verbal skills are essential.
Preferred Qualifications:
- Master's degree preferred.
- General knowledge of legislative and government activities and marketplace issues affecting the region preferred.
- Software skills including Microsoft Word, Excel, Power Point, Access, Project, and Visio preferred.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.