Provider Contract Specialist

POSITION: Provider Contracting Specialist

SCHEDULE: Monday-Friday 8:00AM-4:30PM

LOCATION: Wexford Health Sources Corporate Office – Green Tree, Pittsburgh, PA

BENEFITS:

• 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

POSITION SUMMARY

The Provider Contract Specialist is Wexford’s liaison with all contracted 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.

DUTIES/RESPONSIBILITIES

The Provider Contract Specialist is responsible for developing, maintaining and reporting on the Wexford provider network. 

1. Recruiting new providers, successfully negotiating contracts, and servicing network providers to promote and maintain positive provider relationships.
2. Works cooperatively with regional personnel to identify and target providers needed for network development initiatives and contracts providers at market competitive rates.
3. Manages relationships with assigned contracted providers to ensure that participating physicians are educated about Wexford and are satisfied with the relationship.
4. Successfully follows up on provider leads communicated by UM, Claims, or regional team members.
5. Creates and maintains strong working relationships; works cooperatively with peers and other internal department personnel as part of a coordinated team.
6. Identifies provider education opportunities and prepares appropriate training materials; coordinates, and disseminates information to providers.  Assists in the investigation of suspected incidents of billing fraud and abuse.
7. Secures and/or prepares provider contracting documents, i.e. contracts, credentials, correspondence, etc., in a timely manner to ensure seamless provider transition into Provider Network.
8. Assumes primary responsibility for archival, retrieval and distribution of department documents and reports. Maintains provider contract files and audits yearly for contract and database accuracy.
9. Assists with the credentialing process as needed.
10. Secures and documents current and complete provider demographic information for entry into provider database and WexCare system.
11. Prepare fee analysis spreadsheet on professional providers including UCR in local zip code and local Medicare RBRVS for CPT codes identifies for provider’s type and specialty.
12. Ensures that provider directories accurately reflect information about the network.
13. Contracts/re-contracts providers based on guidelines outlined in department goals, policies and procedures; regularly meets contract completion targets.
14. Cultivates relationships with providers and Wexford regional personnel to ensure accomplishment of departmental and corporate Provider Network goals.
15. Participates in system load, quality control and troubleshooting activities related to provider demographic and contract information in WexCare and other systems.
16. Performs research and problem resolution on issues related to provider complaints; provides assistance to providers experiencing problems with Wexford programs, policies and procedures (e.g. claims, referrals, etc.).
17. Works with associates to identify strengths and areas for improvement with provider relations and contract services.
18. Educates and supports providers regarding Wexford network operations and issues through telephonic contact and individual meetings.
19. 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.
20. Identifies and communicates opportunities for process improvement to management and co-workers.
21. Deals professionally with confidential information.
22. Assists Business Development in preparing responses to Requests for Proposals as needed.
23. Communicates fee schedules and contract provisions to non-network providers.
24. Participates in various internal meetings as a Network Provider subject matter expert.
25. Maintains working log for purpose of tracking all contracting activities.
26. Works on special projects and performs other duties as assigned.

Minimum Requirements:

EDUCATION: Bachelor’s degree in business, health care management, or related field, and/or 3-5 years of relevant experience in the health care industry.

PREFERRED EXPERIENCE:

• Two (2) to four (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.

OTHER PREFERRED KNOWLEDGE, SKILLS AND ABILITIES:

• Good interpersonal skills; ability to establish rapport and work well with others.
• Strong negotiation skills; the ability to gain acceptance from others of a plan or idea and achieve a mutually beneficial outcome.
• Ability to independently plan, organize and prioritize work.
• Detail orientation: systematic and thorough in performance of work.

EOE/M/F/D/V

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