Provider Network Development Specialist

Doctors Healthcare Plans•Orlando, FL

About The Position

This position is responsible for developing, maintaining, and expanding the provider network in the Orlando and Tampa region. The role includes developing, administering, and negotiating agreements with physicians, medical groups, ancillary providers, hospitals, and vendors in compliance with state and federal regulatory guidelines. The specialist ensures contracts use company-approved agreements and comply with requirements from State agencies, CMS, AHCA, and other regulators. The role also collects and verifies credentialing information, ensures agreements are complete, analyzes network needs, determines appropriate payment arrangements within established financial parameters, and supports the accuracy of contract-related provider data. Additional responsibilities include researching claims and utilization for provider re-contracting, comparing potential providers, and completing departmental projects and other assigned duties.

Requirements

Excellent negotiation skills.
Excellent oral and written communication skills.
Bachelor’s degree in health services administration, business, or a related field, or an equivalent combination of training and experience.
Broad financial knowledge.
Knowledge of current Medicare Advantage operational and regulatory guidelines established by CMS, AHCA, and other federal and state regulatory agencies.
Excellent organizational and customer-service skills.
Versatility.
Ability to travel within the Orlando and Tampa region.
Ability to work well under pressure and in difficult situations.
Ability to manage a variety of complex issues while advancing key initiatives.
Excellent knowledge and management of risk relationships.

Nice To Haves

Bilingual English/Spanish.

Responsibilities

Ensure contract language complies with State, CMS, AHCA, and other applicable regulatory requirements.
Use only company-approved Provider Agreements.
Obtain credentialing information for new providers and facilities and ensure it is complete and current.
Ensure all information in agreements is complete.
Negotiate agreements for primary care physician, medical specialty care, ancillary care, and hospital services, as well as agreements for other providers.
Analyze existing networks to determine network needs.
Determine payment arrangements, such as capitation, fee-for-service, or trade agreements, based on financial parameters established by the Network Development Department.
Negotiate contract amendments.
Assist in maintaining the integrity of the provider database as it relates to contracts.
Perform claims and utilization research for re-contracting existing network providers.
Conduct comparative analysis of potential providers.
Complete departmental projects as requested and needed.
Perform other job-related duties as assigned by the VP Network Development and/or President/CEO.