Provider Contract Management Specialist

Portland, Oregon

Cambia Health Solutions, Inc
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Provider Contract Management Specialist

Remote opportunity for residents of OR, WA, ID and UT

Primary Job Purpose

The Provider Contract Management Specialist (PCMS) is responsible for support to ensure accurate development and execution of healthcare provider contracts, support of mass mailings, contract template creation, configuration and maintenance, reporting, and maintenance of the contract database. This position conducts regulatory filings and responds to objections and supports information resourcing for internal and external audits. The PCMS performs research to resolve issues for the Provider Contract Executives, Provider Business Operations, and Provider Enrollment. Provides training to Provider Contract Executives (PCE) on contract management system use and process requirements and training for staff of other departments accessing contract information in the contract database (e.g. Care Management, Audit teams).

The Provider Contract Management Specialist Senior (PCMSS) is more experienced and highly proficient in the use of the contract management system/database and related processes and has expert mastery of operational guidelines and standards. The PCMSS serves as a super-user and subject matter expert (SME). The position compiles contract change requests and facilitates process to determine implementation strategy for contract system updates and operational procedures. This position is responsible for contract management system configuration and maintenance related to contract documents. As a super-user and SME, this role mentors PCMS staff and conducts strategic trainings on using and/or accessing information in the contract management system for peers and cross-functional teams. PCMSS also performs system queries and reporting to identify performance, operational accuracy, potential contract development errors, and ensures ongoing maintenance is performed. PCMSS role collaborates and consults with Provider Operations and other stakeholders to define business requirements, rules and standards to be used for data governance and process improvement. PCMSS is responsible to develop and keep current policies, desk procedures, business processes, and business rules/standards.

General Functions and Outcomes

  • Provides support for internal and external audit, pulling reports or contracts as requested/needed or coaching others on self-sufficient access to needed information.

  • Supports all Plans' mass mailings.

  • Processes all Plans' Single Case Agreements.

  • Triages and investigates claims/audit inquiries.

  • Develops, maintains, and consults on contract policies, procedures, and desk references for the department.

  • Prepares provider contract documents and templates, including technical "coding" and strategic system configuration in the contract management system and completes maintenance.

  • Contracts are built with "technical coding" to drive ability for alternate choices for contract language and for enhanced reporting capabilities, automation, and data governance. Accuracy and attention to detail in sub-coding and configuration is required to drive correct "language and rates" in contractual documents to avoid contractual issues and payment errors.

  • Peer review of documents, system configuration, and contract submissions to OIC is a critical function of this role to promote accuracy and reduce contract administrative and regulatory risks.

  • Conducts system testing of documents and templates, including technical "coding" and system configuration prior to changes being promoted to the system's Production environment. Tests applications and system functionality.

  • Ability to enforce business requirements and standards with PCEs.

  • Works cross-functionally with Network Management staff to draft, coordinate, implement and revise new and renewing provider contracts in a timely manner. Tracks signed contracts to ensure government guidelines are followed. Answers or facilitates resolution of provider contract inquiries as needed.

  • Works with the legal department, regulatory compliance teams, and Network Management contracting staff to file documents, as applicable, with the Insurance Commissioner/Department of Insurance for each state where the Health Plan contracts with providers.

  • Maintains the relationship with the policy and compliance analyst at the Office of Insurance Commission (OIC).

  • Implements contracting policies and procedures for the department.

  • May research, collect, and analyze competitive information for use in contracting and assist with gathering information and responding to RFPs.

  • Assists with coordination, communication, and interaction with stakeholders on the operations of contract language configuration, contracting system operational standards and reimbursement/language configuration for data governance. Assists in answering related questions for internal staff.

  • Implements contracts in the contract management system and coordinates implementation of provider contracts/reimbursement with the Provider Operations, Provider Pricing, and Provider Enrollment staff, including annual fee updates.

  • Provides training and assistance with the contract management system. Instructs others on system use and is the central point of contact for the department in the creation and maintenance of contract documents and templates in the contract management system. Participates in identifying, troubleshooting, and resolving problems.

  • Develops training material and conducts Virtual training sessions.

  • Responsible for the integrity and accuracy of the provider contract database, including ongoing audit of provider information. Effectively maintains contract repository for all contracts. Communicates with all Network Management staff and other divisions as updates are available.

Minimum Requirements

  • Proficient computer skills including use of Microsoft Office products or equivalent software and the ability to learn corporate software programs.

  • Action-orientated approach with ability to effectively organize, prioritize, and meet deadlines.

  • Familiarity with report preparation, including ability to organize and review statistical data and write relevant communications.

  • Knowledge of the contract development process desired.

  • Proficiency in grammar, punctuation, and Microsoft Word formatting.

  • Demonstrated teamwork and collaboration with the peers, leadership, and cross-functional teams.

  • Familiarity with the Regence health care provider community, contracting protocol and reimbursement methodologies desired.

  • Excellent oral and written communication skills to effectively interface and communicate with a broad array of internal and external contacts, including state regulatory bodies.

  • Ability to produce accurate work and focus on details.

  • Proficient in identification of all contract types and payment methodologies and know-how to load into system, to develop contract documents and templates, and to maximize operational usage of the contract management system, including system reporting.

  • Proficient in the use of contract filing software and applications in order to manage regulatory compliance needs related to contract document, template, and provider contract/network filings. Filings must be submitted accurately according to state regulatory guidelines and requirements.

Normally to be proficient in the competencies listed above:

The Provider Contract Management Specialist would have a/an Bachelor's Degree in healthcare, business or related field and 3 years' experience in the healthcare industry with a minimum of one year project-related experience, or equivalent combination of education and experience.

Date Posted: 13 April 2024
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