Develops the iCare’s provider network to best serve the needs of iCare enrollees.
Seeks out opportunities to align providers and encourage performance as measured by HEDIS, P4P, and other quality metrics.
Executes strategies and tactics, developed in collaboration with iCare leadership and other staff, to engage providers in accomplishing iCare goals for improvement in quality and service to members.
Facilitates the development of contracting terms to include incentives for provider performance consistent with CMS Value Based Purchasing and other CMS or DHS provider incentive payment programs.
Negotiates and prepares agreements and contracts for providers to achieve financial and non-financial goals according to iCare policy and limitations.
Interacts with providers to reinforce iCare’s expectations of providers regarding services to iCare members and quality improvement expectations.
Works in collaboration with internal staff to complete and periodically update market analyses to determine network adequacy and identify network development needs.
Develops, in collaboration with team members, strategy and tactics to respond to network development needs.
Works with network providers to assure cultural competency, compliance with quality metrics and adherence to iCare utilization requirements.
Participates in the assessment of the network development opportunities for new products, lines of business and expansion markets.
Recommends content for provider education and training to address contract provisions, the role of iCare’s care management and quality improvement projects, policies and procedures.
Assists in the development of policy, procedures and protocols to ensure network compliance and enhance department efficiencies.
Contributes to organizational efficiency through proper and timely communication of provider agreement terms to appropriate internal teams.
Responds timely to requests from providers relative to contract questions; conducts necessary research and analysis and responds verbally or by correspondence as appropriate.
Interacts with other departments and seeks appropriate resolution to provider/contract issues.
Advises internal staff on issues related to provider contracts and network.
Maintains compliance with all regulatory requirements.
Maintains professionalism and confidentiality at all times.
Conducts presentations to outside agencies and/or organizations directly or in collaboration with other iCare Departments or staff.
Leads or participates in special projects or committees.
Fully participate in iCare’s Compliance Program, including compliance with iCare’s Code of Conduct, policies and procedures, and all applicable Privacy and Security laws
An individual in this position must be able to successfully perform the essential duties and responsibilities listed above. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.
The above list reflects the general details necessary to describe the principle and essential functions of the position and shall not be construed as the only duties that may be assigned for the position.
Broad knowledge of health care marketplace including hospital, physician and other ancillary providers.
Minimum of 5 years’ experience in health insurance/managed care, hospital system, or Accountable Care Organization environment with knowledge of Medicaid and Medicare benefits and services.
Provider or payer contracting experience including Value Based Purchasing, HEDIS/Five Star Program or DHS P4P contract development.
Bachelor’s degree required; emphasis in business administration, health care administration or related field preferred.
Proven negotiation and problem-solving skills.
Excellent oral and written communication skills.
Demonstrated knowledge of Microsoft applications including Word, Excel, PowerPoint, Outlook, and other office software applications. Experience with Provider Database Management Systems preferred.
Must have own vehicle and valid driver’s license for work-related travel.
Bachelor’s degree in business administration, health care administration or related field
Broad knowledge of CMS and DHS activity related to Value Based Purchasing and other provider quality incentive programs.
Experience with Provider Database Management Systems.
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