The Provider Contracting Executive initiates, negotiates, and executes physician, hospital, and/or other provider contracts and agreements for an organization that provides health insurance. The Provider Contracting Executive works on problems of diverse scope and complexity ranging from moderate to substantial.
The Provider Contracting Executive for Ohio Medicaid will communicate contract terms, payment structures, and reimbursement rates to providers. You will be responsible for Ohio Medicaid compliance with network adequacy standards. Maintains familiarity with Ohio Medicaid fee schedules and analyzes comparable Plan pricing guidelines. Ensures capitation, provider rosters, and RHC/FQHC reports are monitored and strategies are developed and plans are implemented to address outliers. Remains current in all aspects of Federal and State rules, regulations, policies and procedures and creates or modifies departmental policies to reflect changes. You will analyze financial impact of contracts and terms. Maintain contracts and documentation within a tracking system. Will identify and recruiting providers based on network composition and needs. Advise executives to develop functional strategies (often segment specific) on matters of significance. Exercises independent judgment and decision making on complex issues regarding job duties and related tasks, and works under minimal supervision. Uses independent judgment requiring analysis of variable factors and determining the best course of action.
- Bachelor’s degree
- Knowledgeable of Ohio Medicaid compliance with network adequacy standards
- Experience negotiating fee for service & capitated reimbursement methodologies for Hospital, Ancillary and Providers specific to Ohio Medicaid methodologies
- Experience communicating the implementation of capitation payments, provider rosters, and RHC/FQHC reports to internal load teams, able to address outliers with provider community
- 5 or more years of progressive network management experience including hospital contracting and network administration in a healthcare company
- 2 or more years of project leadership experience
- Minimum 1-2 years Ohio Medicaid experience
- Extensive provider contracting skills, including contract preparation and implementation, financial analysis and rate proposal development
- Excellent written and verbal communication skills and experience presenting to varied audiences
- Ability to manage multiple priorities in a fast-paced environment
- Knowledge of Microsoft Office applications
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
- Master’s Degree
- Experience with ACO/Risk Contracting
- Experience with Value Based Contracting
This position is considered “remote/work at home”, however, you must live in Ohio to be considered for this opportunity.
Work at Home/Remote Requirements Must ensure designated work area is free from distractions during work hours and virtual meetings Must provide a high-speed DSL or cable modem for a workspace (Satellite and Hotspots are prohibited). A minimum standard speed of 10×1 (10mbs download x 1mbs upload) for optimal performance of is required
Scheduled Weekly Hours