Jul 01, 2020

Manager, Provider Relations and Contracting (70900BR)

  • Professional Diversity Network
  • Linthicum Heights, MD, USA
Contractor Nurse

Job Description


Description: Manages a unit that negotiates, executes, conducts review and analysis, dispute resolution and/or settlement negotiations of contracts with larger and more complex group/system providers in accordance with company standards to maintain and enhance provider networks while meeting and exceeding accessibility, quality and financial goals and cost initiatives. Maintains accountability for specific medical cost initiatives.70900 Fundamental Components: Medicaid background is required.This position is based in Linthicum, MD-partial telework may be availableManages a team of professional analysts and negotiators to negotiate complex, competitive contractual relationships with providers according to prescribed guidelines and financial standards in support of national and regional network strategies. Manages contract performance and supports the development and implementation of standard and/or value-based contract relationships in support of business strategies. Recruits providers as needed to ensure attainment of network expansion and adequacy targets. May manage provider contract support functions including the development of boiler plate contracts and state filings; contract support, review & approval, and information analysis to ensure the development of cost-effective provider contracts. Manages provider compensation/reimbursement and pricing development activities in partnership with business management. Manages the analysts and contract specialists accountable for cost arrangements within defined groups. Collaborates cross-functionally to manage provider compensation and pricing development activities, submission of contractual information, and the review and analysis of reports as part of negotiation and reimbursement modeling activities. Partner with business to determine network and contract needs. Responsible for reporting, understanding and managing medical cost issues and initiating appropriate action in partnership with business. Serves as SME for less experienced team members and internal partners. Provides sales and marketing support, community relations and guidance with comprehension of applicable federal and state regulations.May provide network development, maintenance, and refinement activities and strategies in support of cross-market network management unit. Assists with the design, development, management, and or implementation of strategic network configurations and integration activities.May optimize interaction with assigned providers and internal business partners to manage relationships to ensure provider needs are met. Ensures resolution of escalated issues related, but not limited to, claims payment, contract interpretation and parameters, or accuracy of provider contract or demographic information.Initiate legal reviews as needed; ensure all required reviews completed by appropriate functional areas. Required to communicate w/internal/external parties by phone/in person; may require travel to offsite locations.Medicaid background is required. Background Experience: 5 to 7 years experience in healthcare. A successful track record of managing and negotiating provider contracts that improve competitive position. In depth knowledge of various reimbursement structures and payment methodologies. Solid leadership skills including staff development. Critical thinking and problem solving skills Bachelor's degree or equivalent experience. Masters degree preferred, but not required. Additional Job Information: 7 years of experience in healthcare; demonstration of a successful track record of managing and negotiating provider contracts that improve competitive position; In depth knowledge of various reimbursement structures and payment methodologies; Solid leadership skills including staff development; Critical thinking and problem solving skills; Bachelor's degree in health administration, health systems management, business administration or equivalent experience; Master's degree preferred, but not required.7 years of experience in medical claims processing and administration; including knowledge of inpatient and outpatient claims codes; with an end-to-end understanding of claims submission to adjudication.5 years of Medicaid experience preferred in the Maryland market. 7 years of leadership experience over the following functions: Network Management - Contract negotiationNetwork Management - CredentialingNetwork Management - Physician recruiting - medicalNetwork Management - Provider data servicesNetwork Management - Provider relations Clinical Licensure: N/A Potential Telework Position: Yes Percent of Travel Required: 10 - 25% EEO Statement: Aetna is an Equal Opportunity, Affirmative Action Employer Benefit Eligibility: Benefit eligibility may vary by position. Candidate Privacy Information: Aetna takes our candidate's data privacy seriously. At no time will any Aetna recruiter or employee request any financial or personal information (Social Security Number, Credit card information for direct deposit, etc.) from you via e-mail. Any requests for information will be discussed prior and will be conducted through a secure website provided by the recruiter. Should you be asked for such information, please notify us immediately.#LI-JM1PDN-70900BR

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