Manager - Network Development

MedRisk LLC

21h•Remote

About The Position

This position leads and supports the development, negotiation, management, and maintenance of provider contracts for physician organizations, hospitals, and ancillary facilities across the payment spectrum for HCS’ workers compensation/PIP network. The role involves leading complex negotiations and contracting arrangements, requiring the development of sound business strategies for financial and legal terms. The manager will work with Senior Leadership and Data Analytics to draft provider rate proposals adhering to HCS’s unit cost guidelines and negotiate these proposals directly with hospital executives, physicians, and ancillary providers. Additionally, the position contributes to drafting hospital, professional, and ancillary contract terms to ensure compliance with regulatory, accreditation, and business requirements while advancing HCS’s strategic and business objectives. This manager should have a proven track record in creating, developing, and managing successful network contracting strategies, with experience negotiating contracts with healthcare providers. The role includes leading a team of specialists and independent contributors, requiring excellent communication and leadership skills for effective stakeholder engagement.

Requirements

High School Diploma/GED required.
Requires a minimum of 5 years demonstrated business experience in hospital and provider group finance and/or managed care network development.
Requires a minimum of 5 years in-depth knowledge and understanding of contract finance and reimbursement methodologies including FFS, Workers Compensation/PIP pricing, and incentive arrangements.
Requires a minimum of 5 years prior provider experience in a healthcare setting including but not limited to Workers Compensation, PIP, Commercial, Medicare, Medicaid, and/or Value Based Programs is required.
Requires a minimum of 3 years’ experience in health care cost data analysis.
Requires a minimum of 3 years supervisory experience and/or leading people by influence.
Must be proficient in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint); Should be knowledgeable in the use of intranet and internet applications.
Requires knowledge of principals of health care contracting.
Requires knowledge of health care industry or health insurance industry.
Requires knowledge of the hospital and physician communities in the state of New Jersey.
Requires knowledge of laws and regulations regulating workers compensation and PIP, HMO hospital and physician practice.

Nice To Haves

Bachelor degree preferred or relevant experience in lieu of degree in health or health care related field from an accredited college or university or relevant experience.

Responsibilities

Manage and negotiate contracts in compliance with HCS reimbursement standards.
Assist and implement provider contracting policies and procedures that are consistent with industry best practices and regulatory requirements.
Ensures accurate implementation of contracts in addition to working with other departments to assure contract and special arrangement reporting, provider database maintenance requests, and new hospital implementation.
Conducts research, identify root cause analysis and work fall out reports causing operational deficiencies.
Manages the maintenance of all provider contract language and templates and ensures that all negotiated contracts can be configured into the HCS systems.
Collaborates with Legal and Compliance as needed to modify provider contract templates to ensure compliance with all regulatory, accreditation and business requirements.
Responsible for accurate and timely contract loading and submissions and interface with matrix partners for network implementation and maintenance all lines of business.
Coordination across network management for the submission of hospital, ancillary and professional rate loads, pricing configurations, and contract storage.
Manages the effectiveness and efficiencies of operations which includes management of contract inventory and adherence to all regulatory requirements and internal policies and procedures.
Understands the impact of provider contract provisions on claims payment accuracy and timeliness and presents solutions to minimize unnecessary deviation and supports auto-adjudication.
Understand the credentialing and recredentialing process, provider directory maintenance, and regulatory standards.
Collaborate across departments to ensure that provider services are aligned with the needs of claimants and the organization.
Assist with keeping the provider network integrated with the organization’s objectives.
Provide management level leadership and support all of the contracting staff.
Assist the team with skills, knowledge, and resources needed to effectively manage the provider network and achieve team goals.
Represent the organization at industry conferences, webinars, and other events.
Ensures that HCS is well-positioned to identify and capitalize on emerging trends and opportunities in the market.
Manage, develop and train staff; develop and monitor goals; conduct annual performance reviews, and administers salaries for the staff.