General Summary: Under supervision of Executive Director, BCP & Director, Managed Care Contracting, facilitates contract negotiations, including compliance with regulatory requirements, language appropriateness, delegated credentialing and utilization management and contract operations with payors on behalf of Beaumont Care Partners- Beaumont Health Clinical Integration Network. Responsible for escalation and resolution of claims, authorization, and other issues Payors. Responsible for downstream BCP provider agreements and maintenance. Responsible for provider relations functions and projects that support BCP facilities & physician members with both contracted third party health plans and BCP physician Members and their offices. Responsible for implementation and completion of ACO communications.
Essential Duties:
1. Assists Executive Director and Director with Payor negotiations, implementation, and providing on-going NCQA requirements for Delegated Credentialing Agreements with payors.
2. Recruits and maintains BCP contracts with Beaumont affiliated physicians.
3. Prepares and develops communications on critical information to BCP providers, including contracting opportunities, education on payor requirements, incentive models, contractual terms and obligations, and plan updates through bulletins, newsletters and other media.
4. Service BCP providers on all contract options, questions, and processes for participation with contracted payors. Includes working with payors as needed to ensure provider participation is accurately recorded in their systems.
5. Foster and maintain payor relationships with contracted payors to ensure Provider Relations function can be completed in an efficient, optimal manner.
6. Identifies issues and coordinates problem resolution for BCP providers and payors. Investigates and facilitates resolution of managed care related issues; involves complex and unusual issues requiring creative problem-solving skills.
7. Identifies and targets appropriate physician offices for increased BCP outreach and business development.
8. Introduces and educates clients and potential clients to the plans, programs and services offered through the BCP.
9. Aids Directors in completion of special projects.
Standard Qualifications:
Bachelor's Degree in a subject area related to Business, Health Care Administration, or another related field. Master's Degree preferred.
Three - Five years of previous related experience in a healthcare setting required, preferably working with ACOs, CINs, PHOs, IPAs, etc.
Other Qualifications:
Specific knowledge of Managed Care contracts including Health Plan guidelines, policies/procedures and value based reimbursement as well as experience in a provider service environment.
Planning and organizational skills are extremely important in this position and must demonstrate a strong commitment with respect to exceeding customer expectations as well as resolving issues with a high level of tact and understanding. Must interact effectively as a team member and demonstrate a capacity for high production output and management of multiple projects and shifting deadlines
Previous experience working with physicians required.
Must have proficient verbal and written communication skills and be able to perform highly effective formal presentations.
Must have the ability and flexibility to adapt to change.
Discretion, confidentiality, tact, and sound judgment to deal with sensitive issues
Strong MS Office (Excel, Word, PowerPoint, etc) experience required
