Contract Specialist Clinical Vendor Partnership

Responsibilities:

With oversight from Director Provider Network Management, Manager of Provider Network Management, Network Medical Director and Director of Finance, responsible for overseeing line of business clinical vendor management and relationship development.   

Vendor management:  integration liaison with medical teams and other partner departments across the designated line of business.  Monitoring monthly performance metrics and escalating operation issues to management; oversight of action plan and assistance in collection of penalties if metrics are not met.  Ensures individual state requirements are met. 

Vendor Relationship Development:  with assistance from and review of Plan management:  market needs assessment/RFP, generating written responses and developing business and functional requirements.  Oversee vendor due diligence/selection processes.    Analyze and present recommendations for leveraging added services for overall lower costs to the organization through monitoring of vendor capabilities and new services, analyzing the relationship benefit and sustainable ROI. 

Responsible for the account management, oversight and performance monitoring of ongoing Plan vendor/program partnerships. 

Interfaces with IS, Operations, Provider Network, Procurement, Medical Management, Compliance, Legal, Regulatory, Finance, Communications and Statutory Reporting as it relates to Vendor/Program Management. 

Assures that all reporting and communications related to vendor/program performance is provided to Plan Provider Network Management leadership, Network Medical Director and Director of Finance in a timely fashion and in accordance with NCQA, state and federal requirements. 

Assist in the management of policies and procedures relating to the relationship with vendors and development of programs.

Develop an action plan and assist in collection of penalties if metrics are not met.

Support Network Medical Director and Finance Director in monitoring ongoing quality and financial oversight throughout the life of the relationship. 

The Contract Specialist is responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted value added benefit providers.  The Contract Specialist maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues.  Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products.   Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements.   

The Contract Specialist is also responsible for coordinating the provider application processing functions and related activities for the Plan.  This verification includes confirmation of the State data as required by mandate.  Is an intermediary between the AE’s, providers, State, Plan, Provider Data Management, Clinical Vendor Oversight, and other relevant corporate functions, ensuring accuracy of the application and provider set-up functions.  These activities may include delegations, provider set-up functions, corrections and Network system QA as appropriate on an ongoing basis for the life of the contract.

Education/ Experience:

• Bachelor’s Degree.
• MBA preferred.
• 5 to 10 years experience.

Other Skills:

• Experience in the managed care/health insurance industry with demonstrated strengths in:  knowledge of Plan policies and procedures related to provider contracting, provider credentialing, provider billing and payment, provider incentive programs and other key State and Federal regulatory requirements related to providers, claim adjudication systems, provider file database requirements and relevant software applications;  working independently and managing complex projects and programs both as an independent owner and team leader, interacting at an executive level internally and externally.   
• Experience writing business requirements for contracts and RFP’s.  Experience with contract review and analysis.  Meeting facilitation skills; project management and process definition skills. 
• Prefer substantive Account Executive experience with high impact, high dollar and extremely visible and critical provider groups.