POSITION: Provider Contracting Specialist
SCHEDULE: Full-Time (Mon-Friday 9-5)
FACILITY: WHS Corporate Office
LOCATION: Green Tree – Pittsburgh, PA (onsite)
Wexford Health Sources, Inc. is one of the nation’s largest correctional health care providers. Over the past 30 years, our team of dedicated clinical professionals has helped millions of justice-involved patients receive life-changing medical and mental health services.
The Provider Contracting Specialist is Wexford’s liaison with all physician providers in a designated geographic area. This position conducts and facilitates, on an ongoing basis, all provider contracting and provider relations activities for Wexford’s independently contracted physicians.
• Annual review with performance increase
• Generous paid-time off program that combines vacation and sick leave
• Paid holidays
• Comprehensive health insurance through Blue Cross Blue Shield
• Dental and Vision insurance
• 401(k) retirement saving plans
• Company-paid short-term disability
• Healthcare and dependent care spending account
The Provider Contracting Specialist is responsible for developing, maintaining and reporting on the Wexford physician provider network.
- Takes a lead role in recruiting new providers, successfully negotiating contracts, and servicing network providers to promote and maintain positive provider relationships.
- Works cooperatively with regional personal to identify and target providers needed for network development initiatives and contracts physicians at market competitive rates.
- Manages relationships with assigned individual physicians or medical groups (i.e. hospital based, multi-specialty groups, independent practitioners, etc) to ensure that participating physicians are educated about Wexford and are satisfied with the relationship.
- Determines network adequacy; identifies recruitment needs; develops and implements annual recruitment plan.
- Successfully follows up on provider leads communicated by UM, Claims, or regional team members.
- Creates and maintains strong working relationships; works cooperatively with peers and other internal department personnel as part of a coordinated team.
- Identifies provider education opportunities and prepares appropriate training materials; coordinates, and disseminates information to providers. Creates general communications pieces for the network.
- Assists in the investigation of suspected incidents of billing fraud and abuse.
- Assists in the credentialing process.
- Secures and documents current and complete physician demographic and practice information for entry into provider database and WexCare system.
- Ensures that provider directories accurately reflect information about the network.
- Requests ad hoc reports and utilizes said reports to perform cost per unit analyses for the contracting/re-contracting process.
- Contracts/re-contracts providers based on guidelines outlined in department goals, policies and procedures; regularly meets contract completion targets..
- Cultivates relationships with providers and Wexford regional personnel to ensure accomplishment of departmental and corporate Provider Network goals.
- Participates in system load, quality control and troubleshooting activities related to provider demographic and contract information in WexCare and other systems.
- Performs research and problem resolution on issues related to provider complaints; provides assistance to physicians experiencing problems with Wexford programs, policies and procedures (e.g. claims, referrals, etc.).
- Works with associates to identify strengths and areas for improvement with provider relations and contract services.
- Educates and supports providers regarding Wexford network operations and issues through telephonic contact, individual meetings and group seminars.
- Works with Utilization Management to resolve non-network referral issues; works with the Claims Department to resolve claims issues; develops provider relations plans for educating and communicating to network providers.
- Assists Business Development in preparing responses to Requests for Proposals.
- Communicates fee schedules and contract provisions to non-network providers.
- Participates in various internal meetings as a Network Provider subject matter expert.
- Maintains working log for purpose of tracking all contracting activities.
- Works on special projects and performs other duties as assigned.
The following requirements list the minimum to qualify. An equivalent combination of education and experience may be accepted.
LICENSING: None Required
- Current CPR Certification
- Quality Improvement Certification, preferred
EDUCATION: Bachelor’s degree in business, health care management, or related field
- 3-5 years of experience in the health care industry
- 2-4 years experience in provider relations and/or managed care contracting
- Computer proficiency, preferably in Microsoft Office Suite
- Broad knowledge of managed care plan designs, physician reimbursement methodologies, claims processing, customer service, enrollment, electronic claims transfer, networks and system capabilities
- Knowledge of claims processing systems and guidelines.
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