Payer Contract Specialist

POSITION SUMMARY: The Payor Contract Specialist: Responsible for managing the day-to-day responsibilities related to managed care contracting and payer/provider relations. This includes acting as the liaison between agencies and contracted health plans to disseminate information, research reimbursement and clinical policies, support provider credentialing and onboarding, and resolving claims and other payer issues.

REPORTS TO: Compliance Contract Manager

SUPERVISES: None

QUALIFICATIONS:

Education: Bachelor’s degree is required. Master’s or Juris Doctorate degree is preferred.

Experience: A minimum of 5 years’ experience in a healthcare organization, to include demonstrated leadership in payor contracting. Familiarity with operational, financial, quality assurance, and human resource procedures and regulations is a must.

Core Competencies: Knowledge and understanding of healthcare industry, legal and regulatory requirements. Exceptional and proven provider skills and interpersonal skills. Excellent contract negotiation skills. Results driven and able to self-direct. Strong organizational and analytical skills. Well-developed communication skills. Demonstrated strength in computer software, e.g., Excel, Microsoft Word, PowerPoint, etc.

Other: Valid driver’s license and auto insurance.

FUNCTIONS AND RESPONSIBILITIES:

1. Develop, negotiate, and maintain contracts with all payers, e.g., insurance companies, , MSOs, IPAs, TPAs, and government programs. This includes researching territories to identify gaps with our payer base and supporting the expansion into new markets.

2. Assure contractual arrangements meet financial targets and legal/regulatory compliance requirements. There will be an emphasis on analyzing cost and utilization data.

3. Facilitate the approval process of all contract documents from pre-contract through post-signature phases.

4. Responsible for the accuracy of supporting documentation for contracts and completing documents accurately.

5. Maintain existing relationships with contracted providers. Ensure contractual language is kept current; evaluate fee schedule on a yearly basis to identify possible opportunities for additional covered services, medical policy changes and reimbursement.

6. Complete Medicare enrollment for new entities and markets. Coordinate with internal teams as necessary to support Medicare assignments.

7. Track and report contract renewal dates and alert management 90 days prior to renewal dates.

8. Track contract status and ensure contracts transition to the next stage in the life cycle timely.

9. Monitor for rate renewal, increases, and changes to ensure we realize the intended negotiated contracted rate.

10. Meets routinely with system and health plans to resolve contracting/claims issues.

11. Supports contract negotiation efforts by revenue modeling and rate evaluation.

12. Coordinate and communicate contractual terms to the billing department; ensure staff is informed of changes in medical policy and binning policies.

13. Assure accurate data entry of contract specifications and terms into database and completeness of all contracting processes.

14. Serve as a point of contact on health plan architecture, network restrictions, product offerings and other components of the health plan marketplace.

15. Maintain excellent written and verbal communication with all internal and external customers.

16. Assist with all contracting administration and projects, as needed.

17. All other duties and responsibilities as assigned.