Job Details

Summary

Under the general direction of the Provider Network Operations (PNO) Supervisor, Provider Contracts, the PNO Contracts Specialist manages and supports the administrative and operational aspects of the PNO Contracts Team. Responsibilities include provider negotiations, network research, and analysis. The Specialist performs contract negotiations to close IPA network gaps and meet Federal, State, and Health Plan regulatory requirements. This role also involves maintaining and ensuring the quality of provider contracts to meet market standards for language and rates.

Duties and Responsibilities

·         Prepare, negotiate, and implement contracts and Letters of Agreement (LOAs) for physicians and ancillary providers in diverse areas for existing and developing client IPA networks

·         Identify and resolve provider network adequacy and specialty needs for network growth

·         Ensure contract compliance with DMHC, DHS, CMS, and other regulatory agencies

·         Collaborate with the Contracts Supervisor and PNO leadership to meet departmental goals and requirements

·         Escalate and summarize problematic issues related to payer contracting to PNO leadership

·         Proofread, edit, and fact-check legal documents for accuracy and consistency

·         Work with the Contracts Coordinator to analyze new contract requests (LOIs) and develop proposals

·         Manage the contract lifecycle, including recruiting, negotiating, and contracting with healthcare providers

·         Assess contract rates and identify opportunities to align with market standards and performance

·         Ensure completeness and follow up on provider applications, supporting documents, and Health Plan attestations

·         Log follow-up outcomes and status updates in the LOA Utility; submit the “MPM Contract Routing Checklist” to the database management team as needed

·         Assist the Contracts Supervisor with audit requests from Health Plan, IPA, DMHC, DHCS, CMS, or other regulatory bodies

·         Respond to and close out MPM departmental (Claims, Rates, UM, etc.) and provider-related inquiries promptly

·         Escalate complex rate re-negotiation requests to the Contracts Supervisor; log and track these requests

·         Participate in weekly “B-Report” meetings to provide updates on pre-arrivals, hospital LOAs, and other pertinent topics

·         Ensure HIPAA compliance is maintained

·         Follow MPM Employee Handbook policies and procedures

·         Perform additional duties as assigned

Minimum Job Requirements

·         Bachelor’s degree in healthcare or related field preferred

·         4+ years Managed Care or Healthcare experience in Network Management or Contracting

·         Knowledge of contracting principles and tools, experience in legal/paralegal process a plus

·         EZ-CAP knowledge preferred

·         Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)

·         Substantive knowledge of the HMO marketplace including Medi-Cal, Commercial, and Medicare

Skills and Abilities

·         Strong customer service skills with the ability to resolve complaints and concerns

·         Excellent attention to detail with accurate communication and documentation

·         Proven ability to analyze information and think critically

·         Skilled in multi-tasking, time management, and meeting deadlines

·         Effective in working positively in a dynamic, fast-paced team environment

·         Willing to lead projects beyond the normal job scope