PROVIDER CONTRACTING SPECIALIST

BASIC PURPOSE:

Positions in this job family are assigned responsibilities involving highly responsible work as a liaison between the state insurance program for employees and its network of providers. This includes responsibilities related to establishing and maintaining an effective and viable network of medical and dental providers within the state insurance plan and providing training and assistance to providers.

TYPICAL FUNCTIONS:

The functions within this job family will vary by level, but may include the following:

· Performs network provider services and liaison duties between the state insurance program and participating providers in the health care provider network; provides assistance in resolving problems with claims; explains allowable benefits, coverage provided, fee schedules and other aspects of the program; coordinates problems with other agency divisions and/or third party administrators as required.

· Conducts on-site visits to providers both within and outside the state to provide training, interpret and explain contract provisions and agency policy and procedures, explain claims payment process and billing procedures and provide other information concerning the state insurance program.

· Plans, schedules and conducts visits, meetings and seminars related to the recruitment of additional providers; performs analysis of member demographics, provider and hospital locations, specialty requirements and related information; assists in designing and developing marketing tools such as the recruitment information packets.

· Participates in the development and coordination of an extensive provider network involving in/out of state providers and facilities and in the development of new contracts and application procedures and the production of provider training materials.

· Responds to phone requests from providers and members on a variety of concerns, problems and issues; conducts necessary research and analysis and responds verbally or by correspondence as appropriate.

· Attends meetings, seminars and other training related to the insurance and health care industries; reviews a variety of publications concerning health coverage and treatments to stay informed of changes.

LEVEL DESCRIPTORS:

The Provider Contracting Specialist job family consists of three levels which are distinguished by the complexity of assignments, the level of expertise required to perform the duties assigned, and the responsibility for providing leadership to others.

Level I Code: A33A Salary Band: I

This is the basic level of the job family where employees are primarily responsible for performing routine entry level work in performing the basic functions of a liaison between the state insurance program and network providers and studying resources in a training status to build skills in the areas of claims administration and contractual provisions as they relate specifically to the state plan. Supervisory responsibilities are not assigned at this level.

Knowledge, Skills and Abilities required at this level include knowledge of state and federal laws concerning various types of health and dental insurance programs; of industry guidelines concerning managed health care; and of basic marketing methods. Ability to communicate effectively, both orally and in writing; and to establish and maintain effective work relationships.

Education and Experience requirements at this level consist of a bachelor’s degree and one year of experience in health insurance benefit administration; or an equivalent combination of education and experience.

Level II Code: A33B Salary Band: J

This is the career level of the job family where employees are assigned duties and responsibilities at the full performance level in performing work as a liaison between the state insurance plan and network providers. Incumbents as this level perform a full range of functions related to establishing and maintaining a provider network of doctors, dentists, hospitals, laboratories, medical specialists and other health care professionals for the state insurance plan. Employees may be assigned responsibility for the functional supervision and training of others in performing network recruiting and management duties. Reviews and coordinates trip schedules, training seminars, recruiting visits and other assignments.

Knowledge, Skills and Abilities required at this level include those identified in Level I plus knowledge of the State Insurance Plan and demonstrated ability to manage provider contracts and credentials.

Education and Experience requirements at this level consist of those identified in Level I plus one additional year of qualifying experience.

Level III Code: A33C Salary Band: L

This is the leadership level of this job family where employees are assigned responsibilities for planning, organizing, directing, and supervising all network management and provider recruitment functions which includes overseeing the organization and assignment of work, evaluating employee performance, preparation of employee service evaluations, approving leave and disciplinary actions as required. Incumbents at this level direct the development and coordination of the provider network; implement marketing strategies and recruiting methods; review and analyze existing policies and procedures, reimbursement methodologies, benefit coverage, costs and other features; make recommendations on changes and improvements; serve as primary developer of all provider/facility contracts and applications under the direction of the legal division; chair oversight committee consisting of OSEEGIB medical and administrative staff members to consider recommendations from the credentialing administrator regarding providers applying for participation in the network; prepare and present reports to the Board on member demographics and the status of the provider network; represent the agency at professional seminars, conferences and meetings; prepare articles for publication in newsletters and journals.

Knowledge, Skills and Abilities required at this level include those identified in Level II plus knowledge of supervisory principles and practices. Ability to supervise the work of others; to write reports and make presentations; and to organize and direct the management of a provider network.

Education and Experience requirements at this level consist of those identified in Level II plus one additional year of qualifying experience.

SPECIAL REQUIREMENTS:

Applicants must be willing and able to perform all job-related travel associated with this position.