The Provider Contracting Specialist works in collaboration with the Manager of Provider Contracting and Provider Contracting Supervisor to ensure provider contracts are created and maintained in a manner that consistent with both Community Behavioral Health standards and Federal and State regulations governing practitioner and facility licensing, Medicaid enrollment and reimbursement, and service and financial reporting requirements.
Responsible for obtaining and organizing relevant, accurate information and data required to create, revise and terminate provider contracts for CBH Network Providers, including the completion of all necessary paperwork to support contract changes (i.e. Blue Folders)
Maintains provider contract files in accordance with the standards established by CBH internal policies and procedures governing contract management and external regulatory requirements, including the PA HealthChoices Program Standards and Requirements and PA PROMISe system enrollment guidelines.
Assist in the approval process for out-of-network/non- participating provider contracts
Track contract and licensing application flow, including renewal and termination dates, and provide regular status updates to the Manager of Provider Contracting and Provider Contracting Supervisor
Appropriately notifies all departments regarding contract additions, terminations and changes
Serve as the lead staff for the initial credentialing of facilities entering the CBH Network, to include cross-departmental coordination and collaboration of the required processes and the completion of all necessary paperwork. Credentialing activities include review of provider staff files, business documents, and policies and procedures and provider site visits.
Provide support in determining if Out of Network providers meet CBH and State standards for Medicaid reimbursement, including out-of-state individual practitioners and facilities.
Assist in the cross-departmental provider monitoring process related to newly contracted services, to support the mutual goal of achieving consistency related to the agreed-upon service model
Assure that all Encounter Data associated with paid claims is reported to the PA Office of Mental Health and Substance Abuse Services (OMHSAS) consistent with the Behavioral Health Services Reporting Classification Chart (BHSRCC)
Analyze internal reports related to provider contracts and follow up internally and externally to address any identified issues
Work in collaboration with the Provider Operations, Finance and Information Services Departments to ensure the data in the CBH contract data base is accurate, complete, and up-to-date, including the CBH Level of Care System
Maintain a working knowledge of contracting policies, procedures and processes and provide cross-functional support to other units within the Provider Operations department and other CBH Departments
Works in collaboration with the Manager of Provider Contracting, Provider Contracing Supervisor and the Provider Operations management team to assess current operational efficiencies and recommend and implement process improvements
Represent the CBH Provider Contracting unit at both internal and external meetings
Coverage of the CBH Provider Hotline as assigned
Education: Bachelor’s degree in behavioral health or a related field required, Master’s degree preferred License/Certification: N/A
Relevant Work Experience: Minimum of 5 years healthcare experience, preferably in a behavioral health system with knowledge of managed care and Medicaid programs
Advanced proficiency in various computer applications, e.g. word processing, excel spreadsheet, e-mail, tracking systems, etc.
Excellent communication skills
Knowledge of the PA PROMISe system
Ability to develop alternative solutions to problems; comparing and analyzing data; preparing clear, concise and thorough reports, documents.
Very strong customer service orientation, positive attitude, and change oriented.
Must be able to prioritize multiple responsibilities and manage a large workload within tight deadlines.
Ability to independently plan, organize, prioritize, schedule, coordinate, and make decisions relating to assigned tasks.
Excellent problem-solving skills and self-motivation. Self-starter, takes initiative, and the ability to work independently.
Ability to work with highly sensitive and confidential matters.
Willing to travel locally and regionally for provider agency site visits
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