Provider Contracting Specialist, II

Blue Shield Of California Monterey Park , CA 91754

Posted 2 months ago

GENERAL SUMMARY:

Under the general supervision of the Sr. Manager/Director of Contracting, this position will ensure the acquisition, servicing and performance of Ancillary and Specialty Network Providers to the Blue Shield of CA Promise Health Plan direct contracted network. Support attainment of department goals under the leadership of the Director of Provider Contracting and/or Provider Contracting Sr. Manager and ensures alignment of these goals with the company's strategic priorities. Supports review and modification of contracting and cost of health care savings strategies in anticipation of, and in response to, shifts in provider and competitor negotiating approaches. Researches opportunities within the assigned local market (i.e., network expansion opportunities, utilization or unit cost excesses, etc.) and assesses market trends to drive initiatives which enhance company's market position. Other duties as assigned.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

  • Negotiate and finalize ancillary and specialty network contracts based upon network analysis and established parameters as directed by Director of Provider Contracting and/or Provider Contracting Sr. Manager.

  • Works to achieve operational targets within job area with impact on department results.

  • Works independently on moderately complex projects/assignments and seeks guidance on projects/assignments of higher complexity. Work is reviewed for soundness of judgment and completeness.

  • Sets objectives for own job area to meet the objectives or goals of projects/assignments.

  • Manage contracting efforts through entire procurement process. Ensure contracts are administered and implemented accurately.

  • Work with internal departments to negotiate Letter of Agreements with non- contracted physicians and ancillary providers.

  • Prepare comprehensive network analysis quarterly in order to identify gaps of needed providers.

  • Track and trend data, and identify potential contracting or service-improvement opportunities.

  • Assist with recruitment strategies for targeted providers for ancillary services.

  • Assist with identification of potential providers within targeted area and ensure non- participating providers who are essential to the network are recruited.

  • Work with Director of Provider Contracting and/or Provider Contracting Sr. Manager to ensure that contracting efforts are strategic in nature and results in an effective and high quality network.

  • Responsible for adjusting or recommended enhancements in systems and processes to solve problems or improve effectiveness of job area.

  • Problems and issues faced are general and may require understanding of broader set of issues, but typically are not complex. Problems may require understanding of other job areas. Problems are typically solved through drawing from prior experiences, with analysis of the issue. May make significant departures from traditional approaches to develop solutions.

  • Communicates with contacts typically within the department on matters that involve obtaining or providing information requiring some explanation or interpretation to reach agreement.

  • May work to influence parties within own job function at an operational level.

May provide guidance and assistance to entry level professionals and/or support employees.

QUALIFICATIONS:

  • Bachelor's Degree in health administration preferred or equivalent experience

  • Considerable knowledge of Managed Care, Medi-Cal, Medicare and Cal Medi-Connect lines of business

  • Minimum three years experience in negotiating professional and ancillary provider contracts or equivalent experience to support negotiations

  • Thorough knowledge of provider contracting models and network development

  • Experience in provider relations and client services preferred

  • Strong ability to express ideas clearly in both written and oral communications

  • Ability to develop, organize, analyze and implement processes and procedures

  • Proficiency with Microsoft applications, Word, Excel and Access

  • Effective interpersonal skills

  • Financial and analytical skills a plus

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Provider Contracting Specialist, II

Blue Shield Of California