PRINCIPAL RESPONSIBILITIES:

Under general supervision of the Manager, Networks and Contacting, the Contract Specialist coordinates the day-to-day work processes associated with the contracting process. This includes developing, maintaining and executing contracts (new and revised) as well as changes to DOFRs (Divisions of Financial Responsibilities) affiliated with delegated groups. This position also manages the receipt and development of Letters of Agreement (LOAs).

This position maintains a close working relationship with the Compliance, Finance, Claims, Medical Services, Credentialing, Data Validation and IT departments regarding the status and specifics of provider contracting status and contract contents including payment rates. The Contract Specialist is also responsible for receiving and handling changes in information for non-contracted providers.

Principal responsibilities include:

• Manage the provider contracting process for the Alliance including core contracts and amendments. This includes creation, revision, mailing, scanning and/or filing of contract documents in both paper and electronic systems.
• Manage the addition, revision and termination of provider contracts in the Alliances systems. Ensure accurate updates to Alliance systems are made when contract rates and/or scope of covered services change.
• Oversee creation, revision and/or termination of changes to Division of Financial Responsibility documents (DOFRs) for delegated providers. Communicate needed changes to appropriate departments in a timely manner to ensure proper claims processing and system configurations.
• Negotiate and complete Letter of Agreements (LOA) for non-contracted providers in a timely manner. Receive requests, initiate and complete LOAs when rates are typical for area or historical for a particular provider. Escalate non-standard rates to Director and Manager for negotiation advice and/or handling. Maintain rate templates.
• Manage the addition, revision and termination of provider contracts and LOAs in the Alliance systems.
• Collaborate with Credentialing staff to coordinate review and approval of newly contracted providers
• Effectively manage contracting projects including the maintenance and communication of contract tracking grids.
• Act as primary point of contact and liaison for administrative issues and questions involving contracting process and financial arrangements; receive and screen inquiries, answer questions, resolve routine administrative problems, and/or refer to appropriate department and follow up for resolution. This may include questions from external parties or internal staff such as Claims, Member Services, and Complaints and Resolutions.
• Coordinate communication with providers when changes to practice and/or vendor information are received. This includes, but is not limited to, terminations, address, phone, fax and TIN changes. Ensure that appropriate written documentation of the requested change is on file.
• Ensure updates of non-contracting provider information into Alliance systems is completed on a timely basis.
• Assist in coordination of data for the analysis of network adequacy, expansion of network as necessary and appropriate, and recruitment and retention of providers
• Generate routine and ad hoc reports as requested.
• Assist in coordination of adhering to state and regulatory requirements including reporting requirements.
• Develop tools to monitor payer compliance with contracts and communicate compliance issues to Director and Manager.

ESSENTIAL FUNCTIONS OF THE JOB

Manage the provider contracting process and serve as internal subject matter expert on contracts, reimbursements and the contracting process.

Oversee creation, revision and/or termination of changes to Division of Financial Responsibility documents (DOFRs)

Negotiate and complete LOAs in a timely manner.

Collaborate with Credentialing staff to co rdinate review and approval of newly contracted providers

Manage sensitive contractual information.

Manage key processes to update Alliance systems.

Produce accurate and understandable reports on daily, weekly, and ad hoc basis.

Actively participating in internal committees and meetings

Coordinate and manage communications and/or training associated with the implementation of new or revised contracts.

Coordinate communication with providers when changes to practice and/or vendor information are received.

Problem identification and resolution.

Comply with the organizations Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

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