CareFirst Careers

Institutional and Ancillary Provider Contract Coordinator

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Resp & Qualifications

This position is responsible for contracting and overseeing various components of the provider network and ensuring contracted ancillary or institutional providers (Providers) meet regulatory and accreditation requirements. In addition, support Contract Managers with maintenance of Vendor agreements.  The position represents the organization to Providers assuring an ongoing positive business relationship.  Responsibilities shall include, but not be limited to, contracting, implementation, monitoring and re-contracting as necessary and negotiation and execution of Non-participating Single Case agreements.

PRINCIPAL ACCOUNTABILITIES:
Under the general guidance of the Manager, the associate is/will:

1. Provider contracting, implementation, maintenance, monitoring and re-contracting for standard agreements and non-complex provider specific agreements as necessary for all select network providers as assigned

2. Negotiate, document and manage all Non-participating Single Case rate negotiations as requested by Medical Management.  Obtain required approval from other Blue Plans to negotiate with a Provider outside of the CareFirst service area. Work with internal and external staff to complete negotiations and communicate the agreed upon rates to ensure appropriate claims payment. Obtain Senior Management approval for Non-participating Single Case rate negotiations that exceed 20% of our standard reimbursement.  Monitor and track all Non-participating Single Case rate negotiations and provide management reports.  Monitor and respond to all requests from other Blue Plans requesting the approval to negotiate Non-participating Single Case rate agreements with CareFirst participating network Providers.

3. Manage standard Provider relationship’s and assist Contract Managers with complex Provider relationships (e.g., DRG and per diem arrangements) including determining level of network participation, establishment of payment levels, evaluation of financial feasibility/performance, negotiation of agreements/terms and assure network adequacy for areas of responsibility for all lines of business. 

4. Monitor credentialing for select CareFirst Providers according to the applicable accreditation requirement and assist in credentialing activities as necessary.  Recommend providers for termination as appropriate and identity opportunities for performance improvement and/or for future financial savings.

5. Assist in the development of Standard Operating Procedures and Provider network strategies and if approved, develop and implement the approved network or strategy by sending out RFI’s, establishing Provider criteria and monitoring targeted Providers. 

6. Work with internal and external audit staff to meet frequent regulatory/audit requests.  Design, implement and monitor any required Plan of Action to address the needs of Provider’s and the department’s compliance with regulatory requirements.  When necessary identify recovery opportunities and educate on complex reimbursement methodologies. 

7. Responsible for ensuring Vendor and Provider contracts are consistent and compliant with federal, state and accrediting entity requirements. Coordinate with Legal regarding proposed contractual modifications necessary to meet regulatory compliance or accreditation requirements. Assure compliance with regulatory requirements and quality monitoring. 

8. Assist and support Contract Managers with the maintenance of Vendor and Provider agreements and relationships.

QUALIFICATION REQUIREMENTS:

Required

  • College degree/certification or 3- 5 years of other related significant work experience in job related area may be substituted
  • Understanding of contractual documents
  • Understanding of the healthcare field and various regulatory agencies
  • A general understanding of the accreditation and licensures
  • Must be able to effectively work in a fast paced environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.  Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.   Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.


Abilities/Skills: 

  • Ability to function as a subject matter expert for assigned networks; ability to learn and use electronic contract management system
  • Ability to learn and use Blue Squared to approve and request approval of Non-participating Single Case rate negotiations
  • Ability to effectively communicate terms to internal audiences;
  • Excellent verbal and written communication skills
  • Excellent PC skills in all applicable programs, e.g. Word, Excel
  • Effective time and project management skills to be able to plan and monitor activities to ensure achievement of organizational goals
  • Ability to learn and use department's contract management system - currently Emptoris Contract Management System (ECM)
  • Ability to work independently and as part of a team


Preferred: 

  • Bachelor’s degree preferred, significant work experience in job related area may be substituted 5-7 years
  • Understanding of a rate regulated versus non-rate regulated market
  • Working knowledge of provider community and market and its underlying financial dynamics.

Department

Department: Institutional Contracting

Equal Employment Opportunity

CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer.  It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.

Hire Range Disclaimer

Actual salary will be based on relevant job experience and work history.

Where To Apply

Please visit our website to apply: www.carefirst.com/careers

Closing Date

Please apply before: 4/23/18

Federal Disc/Physical Demand

Note:  The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an associate to perform the essential duties and responsibilities of the position successfully.  Requirements may be modified to accommodate individuals with disabilities.

The associate is primarily seated while performing the duties of the position.  Occasional walking or standing is required.  The hands are regularly used to write, type, key and handle or feel small controls and objects.  The associate must frequently talk and hear.  Weights of up to 25 pounds are occasionally lifted.

Sponsorship in US

Must be eligible to work in the U.S. without Sponsorship

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