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Top Provider Network Contracting Executive

Provides executive leadership and coordination over Provider Network Contracting operations to include development and implementation of strategic plans that provide sound provider interaction and contracting.: Responsible for the research, policy development, contract development and expansion of the provider network. Plans, organizes and directs the Provider Network Contracting department. Organizes, controls, and evaluates the implementation of strategic plans that provide strong provider relations and contracting. Formulates and administers departmental policies. Plans, organizes, implements and evaluates outcomes of the department’s strategic plans. Develops strategic initiatives and transforms initiatives into action plans. Develops and fosters effective collaboration between departments and other affiliated services to ensure an integrated approach to provider network contracting. Develops new strategies to enhance service and improve overall performance. Develops and maintains administrative and regulatory compliance systems. Reviews budgetary recommendations, and manages and monitors the departmental budget. Hires, develops and motivates a qualified staff. An advanced degree is typically required for this position with seven years of provider relations and contracting experience in managed care.

Provider Relations Manager

Oversees and manages the functions of the Provider Relations Department to ensure maintenance or expansion of relationships that meet the business needs of the health plan.: Acts as liaison to physicians, hospitals, members, news media and the general public to ensure effective communication and health plan updates. Responsible for hiring, developing and managing a qualified staff concerned with the maintenance and expansion of provider relationships within the health plan. Prepares and manages the departmental budget. Ensures that the plan has an adequate number of participating providers in the network to meet business objectives. Monitors the provider network to ensure proper recruitment, education and resolution of issues. Oversees contract negotiations with providers and evaluates the provider contracting strategy. Ensures that the provider network is trained. This position typically requires a Bachelor’s degree with five years of health plan experience.

Provider Relations Director

Oversees and manages the functions of the Provider Relations Department to ensure maintenance or expansion of relationships that meet the business needs of the health plan. Manages the provider relations staff and implements strategies relative to the development and management of a provider network. Develops programs to recruit, service, train, and reimburse physicians and providers. Designs and implements programs to maintain positive relationships between the health plan, physicians, providers, and practice managers. Typically requires a bachelor's degree with six years of health plan experience.: Serves as a liaison between physicians, hospitals, members, news media, and the general public to ensure effective communication and health plan updates. Responsible for hiring, developing, and managing a qualified management staff concerned with the maintenance and expansion of provider relationships within the health plan. Ensures that the plan has an adequate number of participating providers in the network to meet business objectives. Monitors the provider network to ensure proper recruitment, education, and resolution of issues. Oversees contract negotiations with providers and evaluates the provider contracting strategy. Ensures that the provider network is trained. Prepares, manages, and monitors the departmental budget.

Provider Network Analyst

Analyzes costs and member accessibility of current and prospective provider networks. Performs a general review of physician costs and practice patterns and analyzes costs and member accessibility of current and prospective provider networks. Typically requires a college degree and two years of experience in data collection and analysis. The position may require contract negotiation experience. : Coordinates and disseminates contract information for the organization. Identifies available networks in each market area and requests detailed provider information from each network vendor for analysis. Matches providers against actual claims experience and produces analyses and reports comparing costs and member accessibility of current network versus prospective network. Performs statistical testing of network vendor discounts. Analyzes general physician costs and utilization patterns by market area. Compares treatment patterns against peer group to identify providers with abnormal variances in cost-effectiveness. May negotiate managed care payer contracts and provider contracts.

Provider Relations Representative

Monitors and coordinates governmental or private health care programs to ensure quality health care and facilitate claim processing; and negotiates contracts for health care programs between insurance companies and health care providers: Analyzes reports and documents regarding health care usage of program participants, utilizing computer; compiles list of recurring health care claims processing issues; develops agenda to address issues; and conducts information and training workshops with employees who process and file claims to resolve claim processing errors. Formulates contract draft of agreement between participants of health care program, utilizing information, such as standard agreement procedures, insurance company policies, and governmental requirements, using computer. Presents health care program contracts to participating parties, discusses modifications suggested by parties involved, and obtains signatures of required representatives on new, renewed, or revised contracts. May monitor phone calls received by medical claim processors to evaluate services offered by employees. May investigate and resolve medical care provider claims reimbursement and program procedural problems. May review evaluation forms completed by workshop participants to determine whether workshop presentation covered processing errors. May specialize in contract negotiations or serve as consultant to facilitate claim processing and be designated Provider Services Specialist (government ser.; insurance; medical ser.).

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