Network Management Representative

WellCare Health Plans Inc. Tampa, FL
Manages physician contracting, network development and provider relations for developing, executing and maintaining a provider network strategy. Works in concert with medical management and sales developing actions to meet market growth and medical cost targets. Provides service and education to network physicians/providers.

DEPARTMENT: Provider Relations/Network Management

REPORTS TO: Sr. Manager, Network Management

Essential Functions:

* Services, contracts and negotiates with primary care, specialty physicians and ancillary providers for all product lines in assigned markets.

* Manages physician network by developing and maintaining relationships to drive business results within a specific geographic area.

* Identifies strategies to achieve Medical Expense Initiatives (MEI).

* Performs ongoing research to identify new providers or areas of expansion in assigned market.

* Responds to provider's contract requests and inquiries.

* Analyzes network gaps and identifies providers to contract.

* Reviews and amends provider's contracts when necessary.

* Evaluates contracted network to ensure functionality.

* Assesses performance and contract rates of providers to ensure our network is cost efficient.

* Researches and develops relationships with non-contracted providers.

* Collects credentialing and required documents for newly contracted providers.

* Strategies for membership growth and retention.

* Performs special projects as assigned

Additional Responsibilities:

* For smaller or emerging markets, the Network Management Representative may perform a dual role with Provider Relation duties. Some associates may perform one or all of the below Provider Relations duties:

* Completes new provider orientation for all applicable product lines.

* Conducts site visits to service providers to provides education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and review HEDIS information. Addresses RxEffect, P4P, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, et al.

* Achieves frequency goals to establish consistent and strong relationship with provider offices.

* Partners with local and national ancillary for appropriate vendor management and coordinates the transition of the delegated providers following a network termination.

* Provides oversight on claims issues. Follows up with providers accordingly.

* Monitors and supports providers using utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve and maintain regions.

* Understands and explains fee-for-service and risk contracts, and provides reporting on provider and/or Service Fund performance.

* Proactively strategies for membership growth and retention, through advanced communication to providers, as well as follow-up to gauge the response to that growth.

* Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.

* Ensures contract SLA's are met, such as meeting with PCP's and Specialists on a monthly, quarterly, or annual basis to address provider panels, after hour's availability and EMR meaningful use.

* Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.

* Partners with finance to identify Medical Expense Initiatives to take actions necessary to successfully complete those initiatives, and assess progress on achieving financial goals.

* Provides continual training to assigned providers on portal and other resources to assist with claims, authorizations, member benefits, etc.

Candidate Education:

* Required A Bachelor's Degree in a related field

* Required or equivalent work experience directly related to Network Development or Provider Relations with demonstrated ability to perform the job duties

Candidate Experience:

* Required 2 years of experience in Provider Relations, Network Management, Hospital Contracting or related Provider Services position with demonstrated ability to perform the level of duties of the position

* Required 1 year of experience in managed care

* Required Other Previous contracting experience

Candidate Skills:

* Intermediate Demonstrated written communication skills

* Intermediate Demonstrated negotiation skills

* Intermediate Knowledge of healthcare delivery

* Intermediate Demonstrated customer service skills

* Intermediate Ability to represent the company with external constituents

* Intermediate Demonstrated interpersonal/verbal communication skills

* Intermediate Ability to multi-task

* Intermediate Ability to analyze and interpret financial data in order to coordinate the preparation of financial records

* Intermediate Ability to work independently

* Intermediate Ability to work within tight timeframes and meet strict deadlines

* Intermediate Demonstrated analytical skills

* Intermediate Demonstrated organizational skills

Licenses and Certifications:

A license in one of the following is required:

Technical Skills:

* Required Intermediate Microsoft Word

* Required Intermediate Microsoft Excel

* Required Intermediate Microsoft Outlook


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