POSITION: Provider Contracting Specialist
SCHEDULE: Full-Time (Monday-Friday 8:30AM – 5PM)
FACILITY: Wexford Health Sources, Inc. Corporate Office
LOCATION: Green Tree – Pittsburgh, PA
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.
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.
- 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
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 literally millions of justice-involved patients receive life-changing medical and mental health services.
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