STAR + PLUS Provider Contract Specialist
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
Responsible for network development; negotiating, monitoring and managing the contractual relationships of assigned providers. Working in coordination with Compliance, Legal, Provider Relations, and Credentialing, and under the direction of Senior Provider Contract Specialist, Manager, Senior Manager or Director, negotiates and finalizes provider contract language and rates, including amendments for existing contracts and establishment of new ones. Contracts for physician, hospital, ancillary, behavioral health, and LTSS providers for Medicaid, Health Insurance Marketplace, Medicare, and any other programs Community may develop. Responsible for provider contract compliance, including regulatory network adequacy requirements. Coordinates with Network Management, Claims, and the Provider Data Integrity team, among others, to ensure adequate set up and comprehensive interpretation of new contract reimbursement and requirements. Assists with provider profiling, working with Provider Relations, Member Services, Provider Services, Healthcare Analytics to provide applicable reports, assist with analysis and recommend actions. Contributes to growth and expansion of the provider networks for any and all existing and/or new lines of business, which may include external meetings with prospective or existing providers for the purposes of negotiating or renegotiating agreements.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Negotiate hospital, physician, ancillary, behavioral health and LTSS provider contract language and rates using established parameters/guidelines.
Serve as a liaison between Community and its providers to facilitate communications, identify issues; resolve problems as they develop, and achieve smooth operations
Contributes to growth and expansion of the provider networks for any and all existing and/or new lines of business, which may include external meetings with prospective or existing providers for the purposes of negotiating or renegotiating agreements.
Assure compliance with regulatory requirements and product requirements related to provider contracting functions, including ensuring network adequacy requirements are satisfied.
Other duties as assigned.
Education/Specialized Training/Licensure: High School Diploma or Equivalent required. Bachelor's Degree preferred.
Work Experience (Years and Area): 2 years experience Healthcare, Providers/Managed Care, Contracting and Relations with degree required.
4 years related healthcare experience in lieu of degree required.
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, Outlook) required.
Other: Must Have Vehicle and Valid State of Texas Driver¿s License required.
Experience with Star Plus, LTSS, HCBPs, and Medicare products a plus.
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Job Status: Full Time
Job Reference #: 166903