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Position Summary
 

This position is located in Pittsburgh, PA. The Senior Network Representative will support the surrounding area.

Please Note: This is not a remote position.

Job Description

 The Senior Network Representative is responsible for all contracting, negotiations, recruitment/expansion, and education functions in the Health Plan. The Senior Network Representative has assigned territories they oversee which includes contracting of existing and new provider groups. Contracting includes working with senior leadership to negotiate high-level language and financial contracting terms. Senior Network Representative works closely with their manager and director to secure large contracts.

 Senior Representative completes all high-level provider educations, including but not limited to new provider orientations, comprehensive, site, and routine trainings. Senior Network Representative prepares and facilitates high-level issue management meetings while meeting deadlines and metrics. They review and resolve high-level provider escalated cases to ensure all parties are compliant. This includes but not limited to delivering clinical, financial, and service value to Martin’s Point Health Plan Members. They must continually access the composition and performance of the provider network. This includes primary care incentive monitoring and CMS Star Ratings. The Senior Network Representative will attend compliance and credentialing site visits to assure we are providing a quality network and meeting HEDIS/NCQA requirements. The Senior Network Representative works closely with the Sales Team to actively recruit new providers to meet or exceed membership growth targets. Also  attends member seminars, charity events, quarterly sales meeting, and other network provider activities.

Key Outcomes:

Network Development

• Handles high level contracting and renegotiations with large and strategic provider groups, and PHO’s, in all our existing or future markets to ensure complex contractual obligations are being met.
• Leads the contracting effort for opening new expansion markets.  and maintains the new education orientation and continues the relationship once contracted.
• Conducts high level provider education in-services and monitors primary care incentive payment, comprehensive payments, and risk arrangements to all existing participating providers.
• Develops PowerPoints including various types of provider education trainings to ensure providers are following our payment policies and are following DOD and CMS requirements.
• Develops PowerPoints and facilitates at all Provider Seminars for Recruitment seminars for new providers through market expansion. to
• Responsible for attending Quarterly Health Plan Sales meetings, submits monthly recruitment reports and presents on key recruitment activity.
• Defines new market expansion areas through research and high-level reporting to compile strategic goals.
• Senior Rep Travels to multiple onsite visits to cover all our geographic footprint.
• Works closely with the Senior Network Operations Specialist and Senior Credentialing Specialist to ensure contracting payments, language, application, and systems are timely and accurately updated.

Network Management

• Liaison for providers and credentialing to ensure delegated agreements are executed
• Senior Network Rep/Partnership with Provider Relations Rep and Network Rep- Performs training, coaching, and mentoring for these two roles.
• Assists with high level audit and special contract projects meeting strict timelines.
• Develops our contract and reimbursement manuals to ensure consistency and accuracy.
• Communicates with providers regarding substantial changes in benefits or policy changes.
• Handles escalated provider issue management cases, payment issues, balance billing cases and providers that are out of compliance.

Education/Experience:

• Bachelor’s degree or equivalent combination of education and experience
• 5+ years of experience in department provider relations and health care including provider contracting involving physician, facility, and ancillary contracts experience

Required License(s) and/or Certification(s):

• Valid driver’s license (no restricted or suspended license)

Skills/Knowledge/Competencies (Behaviors):

• Significant proven advanced knowledge of managed care contracting and reimbursement methodologies
• Understanding of health plan functions and activities
• Proficiency in Microsoft Word, Excel, and PowerPoint
• Superior communication skills, both verbal and written
• Strong analytical skills to coach employees and providers on benefit and payment polices
• Strong negotiations skills
• Ability to make presentations and represent MPHC externally in public forums.
• Strong presentation skills with the ability to speak to large provider groups.
• Strong attention to detail with the ability to organize and execute multiple activities simultaneously.
• Problem-solving skills
• Ability to work collaboratively to meet goals
• Ability to work independently
• Ability to travel with potential overnights at least 50% of the time

There are additional competencies linked to individual contributor, provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.

We are an equal opportunity/affirmative action employer.

Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]