Network Contractor Provider Network Management

The primary responsibility of the Network Contractor is contracting providers, the contracting and re-contracting of providers in an established market. Responsibilities

Supports network development strategy.

Responsible for assisting the Leader with departmental activities related to provider satisfaction, education, and communication.

Responsible for negotiating contracts to execute on network strategy and ensure an adequate, compliant and marketable network.

Responsible for negotiating Single Case Agreements (SCA) rates and converting SCA providers to contracted.

Responsible for recruiting and contracting providers based on identified network adequacy gaps (high complexity).

Ensures all contracts are negotiated to be compliant with Federal and State rules, regulations, policies and procedures and follow all departmental policies.

Ensures contracts are supportive of Plan quality initiatives such as HEDIS, CAHPS and NCQA/URAC.

Negotiates contracts to support management of provider satisfaction.

Contractors will work with Corporate Provider Network Management to manage the annual contracting schedule as well as supplement the network as new providers are available or needed.

Payment/fee schedule SME’s to develop resources in complex specialties i.e. FQHCs, BH, anesthesia etc. These SMEs will be available to AEs when needed for support of claims resolution.

General Operational Knowledge related to provider satisfaction, education and communication with a fundamental understanding of operational items such as claims, payment integrity, provider data, credentialing, appeals disputes etc.

Negotiates provider contracts consistent with claim payment methodologies.

Augments and modifies the existing provider network to accommodate new products or clients as necessary.

Reviews contract language and collaborates with legal to ensure best contract terms.

Support contracting for multiple product lines, including Exchange, DSNP.

Lead negotiator of Value Based Contracting in conjunction with AE.