Medicaid and Medicare Provider Relations Consultant

Health Partners is hiring a Contract Provider Relations Consultant. They manage Health Partners Medicare and Medicaid provider network and provider reimbursement approach.

Overall responsibilities include:

* Establish and maintain positive contractual and strategic relationships between Health Partners and its network of providers, focused on those providers who deliver services exclusively for the Medicare and Medicaid population.

* Develop and implement network contracting strategies consistent with Health Partners overall objectives for Medicare and Medicaid specific covered services.

* Perform project management duties for initiatives designed to enhance strategic contracted partnerships and services for Medicare and Medicaid members

* Work with government programs management to ensure compliance with Medicare product requirements and regulations

* Maintain Health Partners Medicare and Medicaid fee schedules and ensuring alignment with DHS and CMS published IP, OP, professional, & ancillary fee schedules. Perform annual fee schedule increase analysis for budgeting

* Develop and implement sound reimbursement methodologies and value-based contracts that incentivize providers to manage the cost and quality of Medicare and Medicaid members.

* Negotiate contract terms with providers

* Manage the day-to-day operational needs related to providers.

* Supervise and mentor direct reports, including service specialists and contract consultants when applicable.

* Investigate, mediate and resolve inquiries regarding the delivery of care by providers.

* Provide support to the Quality Utilization Management Department in analyzing provider trends and developing action plans to effect change

* Responsible for the supervision of staff, including having the authority to hire, transfer, lay off, promote, discipline and discharge, train, reward and review performance of employees. Ensures compliance to organizational and departmental policies and procedures.

ACCOUNTABILITIES :

* Manage provider network strategies for Health Partners Medicare and Medicaid network, aligning with Health Partners' service area, product and financial goals. Regularly attend internal Medicaid and Medicare strategic meetings providing input on strategic decisions related to Medicare and Medicaid service lines.

* Independently manage and supervise the administrative functions relating to contracted providers who provide services exclusively to Medicare or Medicaid members; including network strategy development, financial analysis, negotiations, contract drafting, contract monitoring, establishing provider relations and communications.

* Independently manage and supervise the implementation of provider contracts with providers who exclusively see Medicare or Medicaid members. Develop systems, policies and procedures to communicate and ensure the successful implementation of contracts by the following internal departments:
Claims, Accounts Payable, Member Services, Clinic Operations, Support Services, Quality Utilization Management, Referral Secretaries, Government Service, Pharmacy Care Network, Sales and Marketing, and Contracting.

* Independently manage and supervise contract maintenance and contract filing functions. Develop and maintain systems and procedures to ensure the collection of credentialing or other oversight provider information. Ensure the contents and filing of contracts and amendments are in accordance with the Minnesota Department of Health, government programs, accreditation and other regulatory agency requirements. Ensure the maintenance of current provider listings for internal uses and to ensure that contracts are current and up to date with all necessary or required contract provisions.

* Monitor contract compliance and adherence to contract provisions by providers and Health Partners for providers who exclusively see Medicare or Medicaid members. Monitor the payment of claims by Health Partners to ensure the correct application of contract payment terms. Take corrective action with providers who are not complying with contract terms, or with Health Partners departments not adhering to contract agreements.

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