Senior Network Representative

Martin’s Point Health Care•Portland, ME

About The Position

The Senior Network Representative contracts, educates, and maintains provider networks that deliver clinical, financial, and service value to Martin’s Point Health Plan members. The role manages provider contracting across the Health Plan, including work in new and existing markets, and continually assesses provider-network composition and performance. This includes monitoring primary care incentives and comprehensive visit performance, managing provider issues, and attending compliance and credentialing site visits to help ensure network quality and compliance with HEDIS/NCQA requirements. The representative works closely with Sales to recruit providers in support of membership growth and participates in member seminars, charity events, quarterly sales meetings, and other provider-network activities. The position leads complex contracting and renegotiations with strategic provider groups and physician-hospital organizations, supports expansion into new markets, and provides provider education and training. It also coordinates with operations and credentialing colleagues to ensure contract terms, payments, applications, language, and systems are accurately maintained. Additional work includes provider issue escalation, audit and contract projects, development of contract and reimbursement manuals, and communication about significant benefit or program changes. The role requires a valid driver’s license and the ability to travel, potentially overnight, at least 50% of the time. Because of the organization’s Department of Defense contract, hires must verify U.S. citizenship and complete employment eligibility verification. The position is not eligible for immigration sponsorship.

Requirements

Bachelor’s degree or an equivalent combination of education and experience.
At least 5 years of experience in provider relations and health care, including provider contracting involving physician, facility, and ancillary contracts.
Valid driver’s license with no restrictions or suspension.
Advanced knowledge of managed-care contracting and reimbursement methodologies.
Understanding of health plan functions and activities.
Proficiency with Microsoft Word, Excel, and Access.
Strong verbal and written communication skills.
Strong analytical skills to coach employees and providers on benefit and payment policies.
Strong negotiation skills.
Ability to present and represent Martin’s Point Health Care externally in public forums.
Strong attention to detail and ability to organize and execute multiple activities simultaneously.
Problem-solving skills.
Ability to work collaboratively and independently.
Ability to travel, potentially with overnight stays, at least 50% of the time.
Must verify U.S. citizenship and complete employment eligibility verification upon hire.

Responsibilities

Handle high-level contracting and renegotiations with large and strategic provider groups and physician-hospital organizations in existing and future markets.
Lead contracting efforts for opening new expansion markets.
Conduct provider education in-services and monitor primary care incentive payments, comprehensive payments, and risk arrangements.
Conduct provider seminars and trainings on payment policies and compliance with Department of Defense and CMS requirements.
Attend quarterly Health Plan Sales meetings, submit monthly recruitment reports, and present key recruitment activity.
Manage hospital capital requests.
Work with the Senior Network Operations Specialist and Senior Credentialing Specialist to ensure contracting payments, language, applications, and systems are updated accurately and on time.
Liaise with providers and credentialing to ensure delegated agreements are executed.
Train and coach new staff members and serve as a role model.
Assist with high-level audits and special contract projects.
Develop contract and reimbursement manuals to promote consistency and accuracy.
Communicate substantial changes in benefits or programs to providers.
Handle escalated provider issues, payment issues, balance-billing cases, and cases involving providers out of compliance.
Recruit new providers in coordination with Sales to meet or exceed membership growth targets.
Attend compliance and credentialing site visits, member seminars, charity events, and other provider-network activities.