Administers all FHHS / PHSO Provider Contracting of physician, ancillary, hospital and facility contracts with assistance from regional leadership, as needed. Works with individual and group practices, as well as the Provider Reps to execute the contracts per region and associate insurance products.
Processes fully executed contracts through the FHHS / PHSO and/or Health First Health Plans provider processing workflows including credentialing and configuration setup, as needed. Monitors current contracts to ensure that contract expiration issues are avoided prior to contract termination date. Works with AHS Florida Division leaders, FHHS, and HFHP to maintain positive relationships with contracted providers.
Works with PHSO Network Operations leadership to develop provider contracts specific to each (West, Central, & East) region. Key providers are identified, prioritized, and tracked throughout the contracting process. Status reports are developed and updated, as needed by region.
Evaluates and implements changes to contracting operations to ensure efficient and effective processes and workflows. Coordinates with PHSO Network Operations and Health First Health Plan (HFHP) to ensure optimal workflows are used.
Determines appropriate use of Letters of Agreement (LOA) and/or temporary contracts as needed including out-of-plan transfers and consults. Prepares and tracks standing LOAs and follows up as needed upon expiration.
Coordinates with HFHP and AHS Legal Services to propose modification to contract language, configurations and provisions to keep contract language in harmony with Florida requirements and CMS/Medicare requirements.
Assists with development of PHSO policies and procedures and standard operating procedures related to the contracting operations. Maintains current knowledge of PHSO and HFHP policies and procedures, as well as state and federal regulatory requirements. Provides appropriate interpretation, clarification of standards and requirements, and suggested changes.
Participates in department or system-wide committees, task forces or activities, when requested. Stays abreast of latest developments, trends, and techniques in areas of responsibility through participating in conferences, workshops, seminars and reading professional literature. Shares knowledge gained with staff and assimilates into department policies and procedures
Responsible for all aspects of filing related to PHSO/FHCA provider contracts. This includes securing fully executed contracts, coordinating with the FHHS workflow to ensure copies are sent to providers, filing the original paper copy, scanning/filing the electronic copy in the Image Now electronic warehouse for contracts, and uploading documents into HFHP system
What You Will Need:
Education and Experience Required:
Two to three years’ experience in a health insurance/HMO payer entity or related field OR
Three years of provider network development or contracting experience
Knowledge and Skills Required:
General knowledge of provider contracts for provider networks/payers including individual and groups of physicians, ancillary provider/facilities and hospitals
Ability to think independently, exercise reliable judgment and problem solve with support of direct supervisor
Written and verbal communication skills, including ability to revise legal provisions in contracts with support of direct supervisor
Support the contract development for the purpose of negotiating contracts to conclusion while matching network development goals for each region in Florida with regional leadership
Ability to react effectively to unplanned circumstances, demands and challenges
Ability to function in a fast-paced and high-pressured environment
Highly-developed interpersonal skills with the ability to relate cooperatively, collaboratively, and constructively with customers, co-workers and staff; while, maintaining confidentiality
Intermediate computer skills, contract warehouse software and information systems knowledge; ability to generate management and production reports, documents and correspondence independently
Current knowledge of Medicare and Florida contracting standards and other regulatory requirements.
Ability to determine the financial impact of all rates negotiations
The Provider Contracting Administrator (PCA) is responsible for the administration of the FHHS / PHSO Provider Network contract strategy, development, and execution. The position will provide direct administration of all aspects of provider contracting with a strong emphasis on defining and owning provider network contracting by PHSO leadership, regional Clinically Integrated Networks (CINs), and providers. The PCA works with the Director(s) of Network Operations and regional leadership with the AHS Florida Division and other providers or networks participating with FHHS / PHSO, Adventist Health System (AHS) Managed Care, AHS employed physician administration, Independent Physician Associations (IPAs), Health First Health Plans (HFHP) to fulfill the mission and goals of Florida Hospital. Actively participates in outstanding customer service and accepts responsibility in maintaining relationships that are equally respectful to all.
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