Senior Provider Contracts Administrator (Hybrid) - Health Alliance Plan

This is a hybrid role with the expectation that the selected candidate must be willing to travel to the Grand Rapids, Kalamazoo, or Traverse City service areas on a periodic basis.

GENERAL SUMMARY :

Through its provider contracting function, HAP is looking to secure Alternative Payment Model (APM) agreements with POs, PHOs, IPAs and clinically integrated network (collectively APM Entities or APMEs) which reward providers for managing the total cost of care (TCOC), quality (e.g. MA Stars), accurate data collection that results in appropriate risk score recognition, general performance improvement initiatives (e.g. leakage avoidance) and member growth.

The Senior Provider Contract Administrator (SPCA) will be responsible for supporting provider contracting for designated accounts as assigned by the Vice President, PNM and under the direction of a Director, PNM using a coordinated team approach, which typical includes the Director, the SPCA and one or more Provider Services Administrators. Contract support will include preparation for negotiation involving a number of financial and other analyses such as unit price benchmarking, price transparency analysis, alternative provider unit price and lower cost setting analysis and certain market competition analyses.

The SPCA will also audit current claims processing unit price configuration against the contract then in effect. During contract negotiation, the SPCA will evaluate counteroffers and their economic impact, and coordinate additional analyses with HAP’s Provider Reimbursement unit if required to determine economic impact or the impact of a change in payment methodology. The SPCA will also document the results of contract negotiation sessions in a transparent process with providers that notes agreed items, open items and the current status of negotiation.

The SPCA will draft contract language from HAP approved templates and furnish to legal counsel for review and approval. The SPCA will document the economic impact of the new agreed unit prices in relationship to the then existing unit prices given an assumed volume benchmark and participate in preparation of documentation to facilitate claims processing configuration of contract unit prices and terms. An SPCA may also be tasked with leading a contract negotiation without Director involvement in negotiations for accounts of lesser dollar volume and monitor implementation of annual rate changes for multi-year contracts for assigned accounts.

PRINCIPLE DUTIES AND RESPONSIBILITIES :

• Assist in the development strategic initiatives that interface with all areas of the company and affect contractual arrangements with providers; Provides subject matter expertise for the development and implementation of provider reimbursement, risk sharing and incentive models.
• Reviews current contract unit prices and validating claims processing configuration.
• Monitors HAP chargemaster limit compliance and changes in percentage of charge reimbursement amounts when chargemaster limits are exceeded.
• Review unit price benchmarks and confirms budget estimates of unit price changes in each negotiation.
• Collaborates with Provider Reimbursement to generate price transparency reports to identify competitor health plan reimbursement levels for the provider.
• Conducts sophisticated financial analysis of historic cost and utilization trends.
• Recommends unit price targets and prepares provider offers.
• Documents HAP contracting objectives and assists in formulation of negotiation strategy.
• Tracks the status of negotiations and prepares associated term sheets.
• Actively participates in contract negotiations and offers ideas and concept to bridge negotiation differences.
• Analyzes counteroffers for economic impact and recommends HAP counters.
• Prepares a summary of the economic value of all modifications to HAP’s initial offer to monitor compliance with budget and actuarial targets.
• Creates the final term sheet that summarizes the essential terms and conditions for inclusion in the agreement upon negotiation completion.
• In collaboration with legal counsel, creates template contracts and drafts provider specific contracts consistent with regulatory and legal requirements and HAP contracting strategy. Manages implementation of new contractual responsibilities for HAP.
• Drafts contract terms and ensures integrity and accuracy of the contracts before executing.
• Secures necessary approvals from HAP leadership and the State of Michigan Office of Financial and Insurance Services and documents the final economic value of the contract and supports establishment of contract benchmarks and annual performance targets.
• Prepares documentation to enable BCT configuration of the claims processing system.
• Assures entry of the contract, along with workflow tracking dates, into the HAP contract management platform.
• Collaborates with the Provider Services team on establishing benchmarks and performance targets for provider performance improvement initiatives.
• Manages the design and implementation of plan-wide initiatives to assess and control costs; improve provider quality; and enhance the member experience; service and accessibility.
• Analyses and designs product specific provider reimbursement policies based on industry standards, HAP operational requirements and cost management objectives.
• Coordinates review, approval, and publication of provider reimbursement models.
• Communicates provider development initiatives and objectives internally to gain partnership from other HAP business units for smooth process-flows; advises and interfaces with senior management to keep them apprised and seek consultation on as needed basis; represents HAP at professional organizations, events and meetings, in the community.
• Monitors financial, quality, service and access performance of providers, using primary research through GQL queries and secondary research of reports prepared by other HAP departments.
• Coordinates the development and implementation of requisite corrective action plans. Presents findings to HAP management and providers. Resolves issues in a prompt, professional, accurate and discrete manner. Proactively discerns the need for ongoing process improvements, alternate options and innovative approaches as necessary.
• Participates in account management for assigned networks and providers, ensuring that all HAP departments understand and meet contracted service agreements.
• Coordinate problem resolution with Claims Processing, Business Configuration Team, Provider Reimbursement, Provider Finance, Risk Adjustment and other departments as necessary.

EDUCATION / EXPERIENCE REQUIRED :

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Additional Information

Organization : HAP (Health Alliance Plan)

Department : Provider Contracting

Shift : Day Job

Union Code : Not Applicable