JOB SUMMARY

The Contracting & Credentialing Specialist initiates, negotiates, and executes Medicare Advantage (MA) physician, hospital, and/or other provider contracts and agreements. The Contracting & Credentialing Specialist also obtains, reviews, and processes physician, facility, and ancillary initial & re-credentialing applications and supporting documentation to approve credentialing and health plan participation.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Draft, review, negotiate, and execute provider, facility, and ancillary contracts and amendments to ensure a high-quality network that helps ensure appropriate reimbursement methodologies are in place (performance incentives, capitation, per diems, creative reimbursement, etc.) to maximize quality and cost savings.
• Maintain contracts and documentation within a contracting system.
• Identify and recruit providers based on network adequacy and marketability in existing and expansion counties.
• Evaluate participation requests against network needs, current contractual relationship, expansion efforts, access to care.
• Make recommendations to the Provider Oversight Committee based on research and contract as requests are approved.
• Complete Single Case Agreements (SCAs) as requested by the Plan’s Utilization Management department.
• Obtain, review, and process physician, facility, and ancillary initial and re-credentialing applications by completing Primary and/or Secondary Source Verification on education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history, and professional competence.
• Maintain credentialing data within a credentialing system.
• Pull monthly reporting to identify expiring certifications, licenses, professional liability insurances, etc. and complete outreach to obtain current/updated documentation and information.
• Assist Manager of Network & Provider Services with preparation, set up, and execution of monthly Credentialing Meetings.
• Fulfill monthly credentialing approval and/or denial letters based on committee’s review and final decision.
• Serve as liaison between provider and committee when/if an appeal regarding a committee decision is received.
• Maintain and monitor delegated credentialing agreements, including performing initial and annual audits for the life of the agreement.
• Assist Provider Concierge team in preparing for New Provider Onboarding, periodic In-Service meetings, Provider Roundtables, etc.
• Builds effective teams by leading with influence, (both internally and externally) to achieve established goals and within established budgets.
• Contribute to a culture of customer advocacy, continuous improvement, and exceptionally high standards
• Establish and maintain a positive working relationship with shareholders, regulatory agencies, and vendors
• Maintains a high level of professional standards with interactions, communications and
• Performs other duties as assigned

EDUCATION AND EXPERIENCE

Education:

• Bachelor’s Degree in business, or other healthcare-related field or five (5) or more years equivalent healthcare work experience

Required Experience:

• 2-5 years’ experience in negotiating Medicare Advantage and/or managed care contracts with physician, hospital, facility, ancillary and/or other provider contracts
• 1 or more year of Medicare Advantage provider relations and/or provider network management experience

Preferred Experience:

• Master’s degree in business or other healthcare-related fields
• Credentialing experience in healthcare
• Experience working with regulatory agencies such as the Centers for Medicare & Medicaid Services
• 3+ years of direct provider interaction

KNOWLEDGE, SKILLS, AND ABILITIES

Required Competencies:

• Knowledge of provider contracts, contract negotiations, provider payment methodologies, claims payment, and provider set up.
• Excellent written and verbal communication skills
• Proficiency in MS Office applications
• Self-motivated with excellent follow-through
• Ability to learn contracting & credentialing program; ability to complete reporting
• Ability to manage multiple priorities and prioritize workload to ensure deadlines are met.

Preferred Competencies:

• Familiar with CAQH
• Knowledge of value-based contracting
• Knowledge of ACO/risk contracting
• Knowledge of provider practice and ancillary provider operations
• Knowledge of local provider community
• Project management

PHYSICAL REQUIREMENTS

• Exerting up to 10 pounds of force occasionally (up to 1/3 of the time) and/or;
• A negligible amount of force frequently (1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body.
• Sedentary work involves sitting most of the time but may involve walking or standing for brief periods of time.
• Jobs are sedentary if walking and standing are required only occasionally, and all other sedentary criteria are met.

****Benefits from Day One:

• Medical, Dental, and Vision Coverage
• 401(k) Retirement Plan with Company Match
• Paid Time Off (PTO) and Volunteer Time Off (VTO)
• Paid Company Holidays
• Health Savings Account (HSA) and Flexible Spending Account (FSA) Options
• Long-Term and Short-Term Disability Coverage
• Employee Assistance Program (EAP) for Personal and Professional Support
• Tuition Assistance for Continued Education
• Pet Insurance for Your Furry Family Members
• Ongoing Professional Development and Training Opportunities
• And an array of additional benefits designed with you in mind

ABOUT HEALTHTEAM ADVANTAGE

HEALTHTEAM ADVANTAGE is an equal-opportunity employer. All applicants will be considered for employment without attention to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran, or disability status.

HealthTeam Advantage (HTA), a Greensboro-based health insurance company, offers Medicare Advantage plans to eligible Medicare beneficiaries in 11 North Carolina counties. HTA has been named a “Best Places to Work” finalist three times by Triad Business Journal. To learn more, visit HealthTeamAdvantage.com.