St. Mary's Good Samaritan Contracting Specialist in St. Louis, Missouri
The Contracting Specialist assists the health plan in ensuring a competitive network by securing needed provider agreements, strategically approaching the provider community and negotiating to the desired contractual and reimbursement terms and prioritizes network contracting needs based upon provider network adequacy and business needs. This position is responsible for managing successful provider contracting negotiations and relationships with required physician specialty care groups, e.g. pathologists, emergency room physicians, anesthesiologists and radiologist groups, along with larger primary care clinics, single site hospitals and small Physician Hospital Organizations. In addition, the Contracting Specialist is responsible for negotiation of limited services agreements covering durable medical equipment, drugs & biologics, reference laboratory, skilled nursing facility care, and/or ambulatory surgery center services, along with assigned single case agreements. This position is also responsible for developing and managing successful provider relationships to facilitate new business opportunities, provider satisfaction and provider retention across DHP/Dean Export products, e.g. commercial HMO, Medicaid, Medicare, Medicare Advantage Part D and Administrative Services Only.
The Contracting Specialist role is further responsible for drafting of unique contract language and customized provider reimbursement terms, which requires thorough understanding and ability to model fixed reimbursements following Centers for Medicare and Medicaid payment models, e.g. RBRVS Relative Value Units, Ambulatory Surgery Groups, and per diem payments, as well as industry-standard managed care terms and conditions.
This position maintains and distributes contract information, and responds to contract inquiries received from DHP’s specialty care physician, primary care clinic and ancillary and limited services providers as well as other internal DHP operations departments so that any required contractual interpretation or input is provided. Providing the operations interpretation of provider contracts to internal departments is a key responsibility of this position.
Essential Job Duties:
To successfully perform this job, the individual must be able to perform each essential job responsibility satisfactorily. Reasonable accommodations may be made to enable an individual with disabilities to perform the essential job responsibilities.
Function as main point of contact for assigned service area for all contractual matters related to specialty care physician groups (e.g. pathologists, emergency room physicians, anesthesiologists, radiologists and other high-volume specialists), larger primary care clinic, and assigned durable medical equipment, drugs & biologics, reference laboratory, skilled nursing facility and ambulatory surgery center providers who participate within DHP/Dean Export provider networks.
Responsible for drafting and negotiating single case agreements that are required when DHP members seek care from non-contracted hospitals, physicians and ancillary providers.
Build and maintain relationships with providers utilizing telephonic, face-to-face and electronic communications.
Independently draft, distribute, negotiate and execute provider contracts, amendments, single case agreements, and letters of agreement
Independently able to negotiate specialty care physician group, larger primary care clinic and ancillary limited services provider contracts, using financial modeling and contract language that meets DHP’s business, regulatory and operational requirements and which are within established guidelines.
Negotiate provider contracts requiring specialized reimbursement terms or customized contract language under direction and support of the Contracting Supervisor and/or Director of Network Contracting and/or Administrative Director – Network Management.
Process and negotiate provider contract amendments and assignments based upon requests received Provider Relations.
Understands and effectively interprets and communicates contract terms and provisions to providers and internal staff.
Process provider contract termination requests received from Provider Relations.
Updates and maintains Network Management Contracting Dashboard(s), SharePoint and Contracting Task List accordingly within Contract Metrics Timeframes
Respond to inquiries and/or concerns received from external and internal parties regarding contract terms; assist in the resolution of contract issues, and obtain assistance from appropriate health plan staff and management, as necessary so that any concerns are resolved in a timely and professional manner.
Assist with DHP’s annual fee schedule review, contract pricing updates—along with preparation of any required contract amendments, and provider distribution processes.
Communicate reimbursement adjustments to providers and collaborate with DHP’s internal staffs to ensure correct contract terms by utilizing all sources including final Provider Set-Up forms are communicated and maintained within DHP’s administrative/claims payment systems.
Collaborate with Network Management and other DHP operations units to determine data requirements for reimbursement decision making. Lead required reimbursement development/analysis in collaboration with Reimbursement & Incentives Analysis Department to ensure complete assessment of reimbursement proposals are completed.
Participates in necessary quarterly provider meetings, as necessary, to review Dean Value Contract provider scorecards/performance relative to the established metrics and tool-kit reports in support of increasing provider performance relative to DHP’s value-based contracting model, as well as sharing the Quarterly Scorecards with the Providers electronically as per SSM/DHP Compliance P&P; guidelines.
Respond timely to internal and external audit and prospective group inquiries.
Assist with joint venture and network service area expansion efforts as required.
Assist with projects and participate in team activities to identify opportunities to improve work processes and systems.
Assist with other special projects, assignments and contracts as assigned.
Bachelor degree in business, healthcare management/administration or health care field, communications or 5+ years of equivalent work experience within a managed care, insurance or provider setting.
3+ years of managed care or insurance contracting experience, or legal office or corporate legal department experience in contract negotiations or administration.
Strong knowledge of managed care products, e.g. HMO, Point-of-Service, PPO, and provider network administration, insurance operations and/or business law.
Excellent problem solving and organizational skills.
Excellent verbal and written communication skills.
Ability to negotiate effectively and independently within established authority levels, under circumstances that can be conflict-laden.
Ability to handle multiple tasks simultaneously, meet time sensitive deadlines and organize workload with general supervision.
Thorough understanding of commercial insurance/Administrative Services Only, Medicare and Medicaid benefits and contracts terms, and reimbursement structures.
Experience working with Microsoft Office Products, including expertise in Word and Excel.
Ability to work independently to achieve identified goals.
Ability to work in a face-paced, multi-task environment.
High level of attention to detail and customer service.
Dean Health Plan, Inc.-
Established in 1983, Dean Health Plan is the insurance services subsidiary of Dean and SSM Health. It maintains a position of leadership in insurance services through a physician-led integrated health system that improves the health of its members and delivers a superior level of service and care. We're looking for talented individuals committed to improving the health of community through innovation, partnership and integrity.
Organization: Dean Health Plan, Inc.
Primary Location: Missouri-St. Louis-SSM Health System Office - 1015 Corporate Square
Work Locations: SSM Health System Office - 1015 Corporate Square (0033.1) 1015 Corporate Square St. Louis, 63132
Job: Clinic & Insurance Operations at Dean Health Plan & Medical Group
Req ID: 18013057