Fallon Health Contract Manager in Worcester, Massachusetts
About Fallon Health
Founded in 1977, Fallon Health is a leading health care services organization that supports the diverse and changing needs of those we serve. In addition to offering innovative health insurance solutions and a variety of Medicaid and Medicare products, we excel in creating unique health care programs and services that provide coordinated, integrated care for seniors and individuals with complex health needs. Fallon has consistently ranked among the nation’s top health plans, and is accredited by the National Committee for Quality Assurance for its HMO, Medicare Advantage and Medicaid products. For more information, visit fallonhealth.org.
Responsible for the analysis, negotiation/renegotiation, implementation, readjustment, evaluation, and continuous improvement of all functions of provider contracting. Manages financial and operational issues related to contractual provider arrangements. Responds to both internal and external customers regarding provider contractual arrangements, both for contract implementation and ongoing operations.
Negotiates, develops and designs contractual provider arrangements including language and pricing methodologies.
Evaluates contractual payment methodologies in order to determine financial risk to insurer and provider (per diem, capitation, discount from charge, DRG, case rate, bundled payments, pay for performance programs , etc.). Ensures the design, production, and distribution of site financial, utilization and member information; ensures the production and completeness of annual site settlement reports. Interfaces between the Plan’s Finance department and individual sites for budget, financial reporting and settlement arrangements for all relevant products.
Performs quantitative analyses of various financial and clinical data in order to evaluate multiple contracting options. Reports performance of ongoing contractual arrangements to appropriate parties.
Manages, coordinates and resolves operational issues related to specific areas of responsibility. Serves as contact person for internal departments (i.e. Claims, Finance, Care Management Services, Patient Relations, Marketing, Credentialing, Provider Relations, etc.).
Researches, analyzes and presents recommendations to Senior Director regarding contractual and financial decisions.
Manages provider correspondence relating to contracts and responds to requests from potential new providers for FCHP.
Maintains computerized tracking system for new and revised agreements. Coordinates and communicates contractual information to appropriate departments within FCHP.
Maintains assigned provider network; physician, hospital, ancillary, and/or carve out vendor as assigned by Senior Director or Manager.
Prepares, updates and maintains files and database for all assigned provider contracts.
Serves as committee member in cross-functional teams as assigned by Senior Director.
Assists in Provider Relations activities including servicing, educating and distributing information to contracted providers.
Analyzes and presents financial reports to providers. Makes recommendations to providers regarding quality and cost improvements.
Other duties as assigned.
Education: Bachelor’s degree or equivalent experience required. Master’s degree in Business Administration, Healthcare Administration, or Public Health preferred. Previous background in nursing or any allied health field is often valuable but not required
Minimum of three years experience in managed care contracting in payer or healthcare environment(s) with related work in provider contracting, healthcare finance, provider reporting/profiling, and/or provider relations. Experience in provider contract negotiations, including FFS, capitation models, and pay for performance models is preferred. Excellent analytical, strategic thinking, and creative thinking skills are required. Superior verbal and written skills, excellent computer skills (Word, Excel, Access) are essential to this position.
Analytic skills using Excel, Access and any predictive modeling or other analytic tools provided by Fallon Health
Negotiating ability that results in continued participation of providers, at or below budgeted cost, in Fallon Health products
Team building skills that are used with both internal and external customers
Problem solving skills to address the sometimes conflicting requirements of internal and external customers
Verbal and written communication skills needed to explain and document complicated financial and operational agreements between Fallon Health and its providers.
Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.
Posted Date 3 months ago (1/8/2021 4:53 PM)
Job ID 6190
# Positions 1
Category Network Development