Director Provider Contracting

Highmark Health•Wilkes-Barre, PA

About The Position

JOB SUMMARY This job is responsible for directing negotiation of the plan’s key contracts with health care providers (hospitals, PHOs, physicians, intermediate care providers). Directs financial analyses of the provider’s payment history, develops approaches to manage the payout consistent with company parameters, oversees the actual negotiation process, and assumes the lead where necessary. Responsible for the development, implementation, maintenance, and updating of the plan’s multiple fee schedules and payment methodologies used to reimburse institutional and professional providers. Implements network contract and reimbursement initiatives as indicated by enterprise and market strategy. ESSENTIAL RESPONSIBILITIES Direct and oversee hospital and institutional provider contract negotiations, taking the lead in complex or high-dollar situations, where appropriate. Negotiate rates for nonparticipating provider services or non-contracted services for applicable products. Coordinate financial analyses and development of strategies for contract negotiations. Manage the design and implementation of provider strategies and reimbursement methodologies aimed at controlling health care costs and evaluate the impact on providers. Develop strategic relationships with key provider constituents and maintain critical communication with institutional and professional providers in sensitive contract discussions or in resolving reimbursement issues. Generally coordinates and has primary responsibility for all provider reimbursement activities within the Plan, including the execution of initiatives in support of enterprise and market strategy. Engage with external consultants as needed to develop and evaluate recommendations related to reimbursement and contract compliance or other reimbursement-related issues. May prepare expansion requests for regulatory agencies, oversee the production of provider directories for members, providers, and community agencies, has responsibility for the provider application process and oversee production of and reviews Access & Availability studies and GeoAccess maps, Alternative Language Studies and Encounter Studies for all states and all lines of business. Facilitate and oversee CACTUS credentialing database functionality and paperless workflow processes through OnBase document management system. Other duties as assigned or requested.

Requirements

Bachelors’ degree in business, finance, information management, healthcare administration or health related discipline or relevant experience and/or education as determined by the company in lieu of bachelor's degree
5 years of experience in health care administration/delivery/finance or a related field
3 years of experience in a management role

Nice To Haves

Master’s degree in Business or Health Care Administration
CPA
working knowledge of third-party payment concepts, and a solid understanding of health care finance and regional market environment
Demonstrated ability to act as a spokesman and interface with external corporate officers and consultants in contract negotiations
Superior ability to analyze data and reimbursement methods to determine strategies and issue resolution in negotiations and other business matters

Responsibilities

Direct and oversee hospital and institutional provider contract negotiations, taking the lead in complex or high-dollar situations, where appropriate.
Negotiate rates for nonparticipating provider services or non-contracted services for applicable products.
Coordinate financial analyses and development of strategies for contract negotiations.
Manage the design and implementation of provider strategies and reimbursement methodologies aimed at controlling health care costs and evaluate the impact on providers.
Develop strategic relationships with key provider constituents and maintain critical communication with institutional and professional providers in sensitive contract discussions or in resolving reimbursement issues.
Generally coordinates and has primary responsibility for all provider reimbursement activities within the Plan, including the execution of initiatives in support of enterprise and market strategy.
Engage with external consultants as needed to develop and evaluate recommendations related to reimbursement and contract compliance or other reimbursement-related issues.
May prepare expansion requests for regulatory agencies, oversee the production of provider directories for members, providers, and community agencies, has responsibility for the provider application process and oversee production of and reviews Access & Availability studies and GeoAccess maps, Alternative Language Studies and Encounter Studies for all states and all lines of business.
Facilitate and oversee CACTUS credentialing database functionality and paperless workflow processes through OnBase document management system.
Other duties as assigned or requested.