Provider Relations and Contracting Specialist

Job Description

Job Description

The role of the Provider Relations and Contracting Specialist is to provide FrontPath members and their enrollees with access to a broad and cost-effective provider network. The role focusses on retaining and growing the network providers through building ongoing and trusted working relationships with providers and through delivering excellent provider service. The Provider Relations and Contracting Specialist coordinates the resolution of provider issues with appropriate FrontPath leader or staff.

Major Areas of Responsibility :

• Leads the provider contracting process with new and current participating providers, including standard processes for review of requests for participation, contracting and negotiations for facility, ancillary and professional providers.

· Oversees, conducts and documents facility, ancillary and professional delegated and direct recredentialing cycles. Ongoing monthly review of CAQH Summary reports to identify any listings related to FrontPath providers.

· Maintains an accurate and up-to-date provider database for use in network management, claims repricing and the provider directory. This includes weekly and monthly reporting of provider files to TPAs and weekly updates to the provider directory.

· Assists the FrontPath customer service specialist, and coordinates distribution of problems for resolution to the appropriate FrontPath leader or staff. Conducts personal follow-up with providers, brokers or TPAs on provider related issues and topics.

· Manages the implementation process (provider adds) for all new providers and for implementation of new negotiated facility and ancillary provider rates.

· Coordinates FrontPath resources to respond appropriately to provider inquiries on claims repricing topics and issues.

· Manages communications with providers; provide appropriate educational opportunities and resources; respond to provider claims inquiries, requests for fee schedules and related information.

· Oversees Claimshop user access for members and providers, including loading into ClaimShop and periodic reverification with provider groups and members.

· Negotiates Single Case Agreements with out of network providers or large case agreements with existing tertiary participating providers at the request or with the approval of the plan sponsor.

• Assists in the claims repricing function by processing assigned Pend Codes as required in a timely manner.

· Works collaboratively with internal and external stakeholders to foster strong relationships between FrontPath and network providers to provide value and access to FrontPath members.

• Carries out other duties as assigned.

Experience Required :

• Minimum Bachelor’s degree from an accredited college or university or equivalent relevant work experience.

• 3 + years related work experience, primarily including provider contracting or claims oversight functions.

· Demonstrated knowledge relative to local provider and purchaser markets.

· Demonstrated ability and proven track record to create and foster strategic relationships with key stakeholders at provider organizations.

• Demonstrated ability to use analytics to inform rate negotiations and strategic decision-making.

• Excellent oral, written, and interpersonal communication skills.

• Proven ability to work within a team and to foster teamwork.

• Strong planning, problem-solving, time management, organizational and prioritization skills.

· Demonstrated skill in use of Word, Excel, Access, Power Point, Outlook.

This is a full-time position reporting to the President and Chief Executive Officer.