Network Management Contract And Benefits Specialist

Martin's Point Health Care Portland , ME 04101

Posted 3 weeks ago

Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.

Position Summary

Job Description

Position Summary:

The Contracts Benefits Specialist position has a high level of responsibility for maintaining and monitoring our provider network contracts to assure accuracy with regard to language, payment methodology and to ensure all contracts are compliant with all CMS and DHA regulatory requirements. This role includes network development in new service areas (i.e., provider contracting) as well as maintaining positive relationships with previously contracted providers (Provider Relations) .The Contract Benefit Specialist will troubleshoot high level complex provider related reimbursement issues, strategic planning with regard to payment and benefit changes, outreach to represent the department in both internal and external meetings. The Contract Benefit Specialist must demonstrate advanced knowledge of all Health Plan product lines.

Key Outcomes:

  • Manages existing contracts ensuring contracts are compliant with our USFHP and GA Programs

  • Works closely with MCA and other departments to assure newly negotiated contracts with special reimbursement can be operationalized prior to contract execution. (Risk contracts, cap payments, incentive reimbursements, etc.)

  • Modifies, updates and maintain contracts associated documentation, processing and communicating changes to providers

  • Understands and explains fee-for-service and risk contracts, and providers reporting on provider performance.

  • Ensures new provider contracts are complete and uploads them to our appropriate internal systems and file directories

  • Annually reviews Provider contracts and monitors provide compliance and quality Ensures adherence to contractual obligations and regulatory requirements

  • Coordinates with BAD Team to provider benefit and reimbursement communications to Network Management that may have an impact with our contracted providers

  • Acts as a liaison between internal departments to establish policies and procedures to maximize work flows

  • Identifies system and processing enhancements for Claims, HMD, Provider Inquiry, and Member Services

  • Maintains customer service tracker (specific to operational issues between claims, member services, provider inquiry) in coordination with customer service to enhance provider and member satisfaction

  • Assists Provider Relations Managers or Director with preparation and presentation of departmental or plan audits and reviews, (e.g.,CMS, NCQA)

  • Communicate network issues and opportunities to Plan Management

  • Facilitates improved work flows within the department and cross functionally

  • Maintain updates to our internal process manual and employee training manual

Education/Experience:

  • Bachelor's degree or equivalent combination of education and work experience

  • 2+ Years' experience in managed care, preferably provider contracting and network management

  • Knowledge of managed care contracting and reimbursement methodogies

  • Proficiency in Microsoft Word, Excel and Access Office Products

  • Oral and Written communication skills

Required License(s) and/or Certification(s):

Skills/Knowledge/Competencies (Behaviors):

  • Strong negotiations skills

  • Excellent interpersonal skills

  • Ability to make presentations and represent MPHC externally in public forums

  • Ability to organize and execute multiple activities simultaneously

  • Problem-solving skills

  • Demonstrated ability to work independently to meet goals

  • Strong collaboration skills

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin's Point Health Care? Contact us at: jobinquiries@martinspoint.org


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Network Management Contract And Benefits Specialist

Martin's Point Health Care