Contract Provider Relations Consultant

HealthPartners is hiring a Contract Provider Relations Consultant. They manage HealthPartners Medicare and Medicaid provider network and provider reimbursement approach.

Overall responsibilities include:

• Establish and maintain positive contractual and strategic relationships between HealthPartners and its network of providers focused on those providers who deliver services exclusively for the Medicare and Medicaid population.
• Develop and implement network contracting strategies consistent with HealthPartners overall objectives for Medicare and Medicaid specific covered services.
• Perform project management duties for initiatives designed to enhance strategic contracted partnerships and services for Medicare and Medicaid members
• Work with government programs management to ensure compliance with Medicare product requirements and regulations
• Maintain HealthPartners Medicare and Medicaid fee schedules and ensuring alignment with DHS and CMS published IP OP professional & ancillary fee annual fee schedule increase analysis for budgeting
• Develop and implement sound reimbursement methodologies and value-based contracts that incentivize providers to manage the cost and quality of Medicare and Medicaid members.
• Negotiate contract terms with providers
• Manage the day-to-day operational needs related to providers.
• Supervise and mentor direct reports including service specialists and contract consultants when applicable.
• Investigate mediate and resolve inquiries regarding the delivery of care by providers.
• Provide support to the Quality Utilization Management Department in analyzing provider trends and developing action plans to effect change
• Responsible for the supervision of staff including having the authority to hire transfer lay off promote discipline and discharge train reward and review performance of employees. Ensures compliance to organizational and departmental policies and procedures.

ACCOUNTABILITIES:

1. Manage provider network strategies for HealthPartners Medicare and Medicaid network aligning with HealthPartners service area product and financial goals. Regularly attend internal Medicaid and Medicare strategic meetings providing input on strategic decisions related to Medicare and Medicaid service lines.
2. Independently manage and supervise the administrative functions relating to contracted providers who provide services exclusively to Medicare or Medicaid members; including network strategy development financial analysis negotiations contract drafting contract monitoring establishing provider relations and communications.
3. Independently manage and supervise the implementation of provider contracts with providers who exclusively see Medicare or Medicaid members. Develop systems policies and procedures to communicate and ensure the successful implementation of contracts by the following internal departments:Claims Accounts Payable Member Services Clinic Operations Support Services Quality Utilization Management Referral Secretaries Government Service Pharmacy Care Network Sales and Marketing and Contracting.
4. Independently manage and supervise contract maintenance and contract filing functions. Develop and maintain systems and procedures to ensure the collection of credentialing or other oversight provider information. Ensure the contents and filing of contracts and amendments are in accordance with the Minnesota Department of Health government programs accreditation and other regulatory agency requirements. Ensure the maintenance of current provider listings for internal uses and to ensure that contracts are current and up to date with all necessary or required contract provisions.
5. Monitor contract compliance and adherence to contract provisions by providers and HealthPartners for providers who exclusively see Medicare or Medicaid members. Monitor the payment of claims by HealthPartners to ensure the correct application of contract payment terms. Take corrective action with providers who are not complying with contract terms or with HealthPartners departments not adhering to contract agreements. Participate in year end contact settlement process where appropriate.
6. Develop and implement appropriate Medicare and Medicaid reimbursement methodologies such as capitation case rates fee schedules per diems Ambulatory Patient Classifications Diagnostic Related Groups and value-based contracts.
7. Monitor analyze and interpret financial and utilization patterns of Medicare and Medicaid providers. Implement corrective action steps as necessary.
8. Manage the operational financial and administrative relationships with providers. Provide support to the Medical Director Associate Medical Directors and Department Heads to coordinate communications and operations.
9. Participate in annual planning exercise for Medicare and Medicaid lines of business

10. Provide project management for a variety of strategic development projects for Medicare and Medicaid lines of business. Develop project plans and approaches for problem solving; assist executive leadership in determining major deliverables and identifying project responsibilities establish project time lines define checkpoints and determine appropriate structures for relationships. Lead implementation of project plans.

REQUIRED QUALIFICATIONS:

• Bachelors degree in health care administration business administration or other relevant field.
• Minimum of seven years experience working in the health care industry with three years working in a provider relations/provider administrative role.
• Previous experience in a management position independently responsible for planning and development of a key company function.
• Strong analytical and financial modeling skills.
• Ability to develop and evaluate contracting strategies.
• Strong oral and written skills with the ability to make effective group presentations and consensus building.
• Excellent team leadership skills with a sound level of interpersonal effectiveness.
• Ability to work independently making independent decisions as they relate to the successful relationships with providers consistent with HealthPartners goals.

PREFERRED QUALIFICATIONS:

• Strong financial and systems background.
• Previous experience in Medicare and Medicaid provider contract negotiations
• Previous experience in health care industry with Medicare and Medicaid lines of business
• An additional two years experience in network development in specific products e.g. workers compensation.

MAJOR CHALLENGES:

Establishing a successful working relationship with providers professional staff legal counsel and/or board members. This requires independent decision-making and strong negotiating skills with a constructive approach toward problem resolution.

Manage the administrative requirements of HealthPartners for all products offered.

DIMENSION:

• Actively participate in creating and managing a successful provider networks serving approximately 600000 HealthPartners members with revenues of approximately $2.0 billion.
• Actively responsible for managing contract costs within the departments operating budget.
• Directly supervise direct reports including service specialists and contract consultants when applicable.