Senior Provider Contract Manager

PacificSource Health Plans • Bend, OR

2d • $83,310 - $145,793 • Hybrid

About The Position

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, sex, sexual orientation, gender identity, national origin, genetic information or age. PacificSource values the diversity of our community, including those we hire and serve. We are committed to creating and fostering a work environment in which individual differences and diversity are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths. Responsible for helping develop and maintain successful execution, coordination, and evolution of all lines of business, value-based, and alternative payment methodology contracts (VBP/APM). Work with internal PacificSource staff as well as external partnership representatives, such as physicians, executive management, and clinical/office staff, to create a plan of collaboration, implementation, and success for VBP/APM initiatives. Plan initiatives will focus on defined short- and long-term targets pertaining to cost containment, quality improvement, patient satisfaction, and company strategic plan initiatives. Encourage innovation and help build collaborative provider relationships to achieve PacificSource’s strategic goals.

Requirements

• Minimum of 6 years of experience within the health insurance industry, provider organization, or related field in provider reimbursement.
• Experience should include high-level contract negotiation for all lines of business (i.e., value-based contracting), alternative payment methodologies, understanding of complex financial analysis related to hospital and provider reimbursement, contract implementation, contract management, and collaboration and relationship development with senior executive leadership.
• Bachelor’s degree in business, health care administration, finance, or equivalent years of additional relevant experience in lieu of degree required.
• Understanding of the following areas: cost and utilization management, quality initiatives, evidence-based medicine and care coordination required.
• Thorough understanding of financial arrangements and quality programs across health care products and lines of business.
• Knowledge of CPT, HCPC, and ICD-10 coding methodologies required.
• Possess data management skills, knowledge of regulatory issues and network development.
• Requires project management skills including provider relations, time management, coordination with other staff, and resource usage.
• Demonstrated successful communication skills, including public presentation, training, meeting facilitation, and/or broker/agent/provider presentations.
• Strong interpersonal skills coupled with the ability to foster positive working relationships.
• Knowledge of health insurance products and service design, concepts, practices, & procedures.
• Strong experience in the provider environment.
• Self-starter and the ability to lead with minimal direction.
• Proven ability to lead and mentor small teams.
• Ability to travel throughout business territory.

Nice To Haves

• AAPC coding certification preferred.

Responsibilities

• Serve as lead on high-tier provider contracts with key partners, which include Joint Operating Committee accountabilities, multiple lines of business, upside and downside risk models, shared savings, quality metrics and program payment reimbursement.
• Serve as primary contact with provider partners for all lines of business contracting including, but not limited to, capitation, risk models, shared savings bonus models, ACO and CCO models, full and partial capitation arrangements, program payments (including Patient Centered Primary Care Home), DRG, fee-for-service, RBRVS, per diem, per case, CMS methodologies, percent of charges and episodic payments.
• Serve as primary contact with Medicaid provider entities which include non-emergent medical transportation, community-based organizations, dental care organizations, interpreter vendors, and other unique provider types.
• Manage provider contractual relationships for the dual special needs population (DSNP), and the PACE program
• Assist in supporting project plans which may include provider accountability deliverables, innovative reimbursement models, milestones, and quality measurements and revise as appropriate to meet changing needs and requirements.
• Assist in development and implementation planning of contractual agreements within PacificSource, including all organizational support such as sales, marketing, clinical, actuarial, analytical, underwriting, and technical assistance.
• Ensure consistency with progressive strategies of PacificSource that pertain to provider relationships and their ability to affect change and reform in the health care system with feedback from EMG, management staff, and others on the cross-functional team.
• Provide support to management related to PacificSource’s evolution of current and potential new opportunities for contracting strategies.
• Keep informed of the evolution of current strategies in discussions related to reform, payment methodologies, risk arrangements, quality metrics and participate in related ongoing analysis.
• Proactively develop positive working relationships with other PacificSource departments and staff to resolve provider issues.
• Develop thorough knowledge of system capabilities related to analytics, quality metrics, Facets setup, Facets Business Support, other supporting systems.
• Exercise independent judgment and communicate effectively between internal and external team members.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Maintain clear understanding of system set-up and reporting requirements/limitations as required by contractual obligations.
• Participate in provider specific and public presentations as required.
• Assist in leading, shaping and developing special projects related to PacificSource initiatives.
• Perform other duties as assigned.

Benefits

• Flexible telecommute policy, medical, vision, and dental insurance, incentive program, paid time off and holidays, 401(k) plan, volunteer opportunities, tuition reimbursement and training, life insurance, and options such as a flexible spending account.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Number of Employees: 501-1,000 employees