Provider Contracting Associate Manager, Manager or Sr. Manager

PEHP Health & Benefits is a division of the Utah Retirement Systems that proudly serves Utah’s public employees through high quality and competitively priced medical, dental, life, and long-term disability insurance plans on a self-funded basis. As a government entity, we embrace both a public mission and a commitment to creating customer value, excelling in the market, and improving healthcare. We offer a competitive salary with generous benefits, personal development in a positive team environment, and excellent work-life balance.Provider Contracting Associate ManagerFLSA: Non-ExemptPOSITION SUMMARYThe core responsibility of this position is to manage a range of provider relationships to enable and enhance PEHP’s competitive position in the market and to function as an internal contact on technical, operational, and escalated issues that pertain to providers. Duties include supporting network relationships, acting as a point of contact for identified providers, negotiating provider contracts, advising other departments on provider issues, coordinating efforts within Clinical Management, basic analytical support, and resolving technical and escalated matters. Successful performance of this position requires achievement of contractual, network management, and internal operational objectives while demonstrating an expanding knowledge of PEHP policies and practices related to providers, current and emerging payment methodologies, the Utah Healthcare Market, and internal operational processes together with sound analytical, interpersonal, and negotiation skills. ESSENTIAL JOB FUNCTIONS AND DUTIES

Participates in the ongoing negotiation and development of network/provider contracts and relationships. Formulates and develops contractual agreements between providers and PEHP consistent with organization objectives.

Analyzes reimbursement structures and contracts. Ensures contractual agreements meet financial and legal requirements.

Maintains existing relationships with contracted providers. Reviews financial performance of contracted providers one or more times per year.

Coordinates and communicates contractual terms to the Administrative Systems and Project Management, Actuary & Data Analytics, and Finance departments.

Participates in the ongoing assessments of assigned networks. Recommends changes to meet PEHP objectives. Reports monthly on contract status.

Assists with contracting administration and projects as needed.

Understands fundamental concepts in various reimbursement methodologies including but not limited to resource-based relative value scale (RBRVS), diagnosis-related group (DRG), ambulatory payment classifications (APC), discount from charges, capitation, per diem, and per case methods. Incorporates reimbursement methodologies into provider contracts to improve quality and manage cost.

Resolves provider concerns escalated from other departments.

Initiates and manages standard reimbursement contracts and single case agreements.

Attends external meetings as a representative of PEHP.

Serves as a provider contracting resource to other departments.

Participates in the development of preferred provider membership criteria.

Maintains strict confidentiality.

Performs other related duties as required.

Provider Contracting ManagerFLSA: ExemptPOSITION SUMMARYThe core responsibility of this position is to manage a range of provider relationships to enable and enhance PEHP’s competitive position in the market and to function as a key internal contact on technical, operational, and escalated issues that pertain to providers. Duties include managing network relationships, acting as a point of contact for provider relationships, negotiating provider contracts, advising other departments on provider issues, coordinating efforts within Clinical Management, providing analytical and strategic input, and resolving technical and escalated matters. Successful performance for this position requires achievement of critical contractual, network management, and internal operational objectives while demonstrating a deep knowledge of PEHP policies and practices related to providers, current and emerging payment methodologies, the Utah Healthcare Market, and internal operational processes together with excellent analytical, interpersonal, and negotiation skills. ESSENTIAL JOB FUNCTIONS AND DUTIES

Responsible for enabling and enhancing PEHP’s competitive position in the market by acting as a key point of contact, negotiating favorable contracts, and managing PEHP’s network of providers.

Formulates and develops contractual agreements between provider and PEHP. Performs analysis of reimbursement structure, data, addresses, and coding issues.

Accountable for and maintains updates on, policies and development of PEHP Provider Network, provider profiling, and provider office in-service.

Responsible to be current in understanding the various reimbursement methodologies, including but not limited to resource-based relative value scale (RBRVS), diagnosis-related group (DRG), ambulatory payment classifications (APC), discount from charges, capitation, per diem, and per case methods. Responsible for negotiating and creating contracts that incorporate the various methods of reimbursement.

Negotiates unique reimbursement contracts with contracted providers as well as single case agreements with non-contracted providers.

Analyzes and researches complex issues related to PEHP providers and develops alternative solutions within the framework of established guidelines and legal regulations. Designs and recommends changes to programs, contracts, policies, and procedures.

Meets all team deadlines and responsibilities, helps other team members maximize potential, helps team members meet goals, promotes a team atmosphere, and provides coaching and training as requested.

Attends internal management meetings as a representative of the Provider Contracting Team and provides input and takes assignments for company initiatives. Attends external meetings as a senior representative of PEHP.

Trained as an additional resource for the Fraud Supervisor.

Serves as an internal liaison for other departments with education, problem resolution, and communication issues related to provider contracting.

Develops guidelines and practices to enhance efficiency and effectiveness of provider-related matters.

Facilitates changes in provider relations policies and contracts. Takes a leading role in the approval and implementation of policies and contract changes across all departments within PEHP.

Directs development of preferred provider membership criteria and supports screening of applicants.

Coordinates with and supports the Member and Provider Services department and Intake team to resolve escalated provider concerns.

Tracks provider-related data to evaluate trends and garner insights.

In conjunction with PEHP Marketing, develops, edits, updates, and inputs content for provider-related communications, including letters, newsletters, and internal and external web pages.

Oversees the dental provider network including development and management of fee schedules.

Maintains strict confidentiality.

Performs other related duties as required.

Provider Contracting Sr. ManagerFLSA: ExemptPOSITION SUMMARYThe core responsibility of this position is to manage key provider relationships to enable and enhance PEHP’s competitive position in the market. This position plays a vital role in PEHP’s efforts to mitigate rising medical costs, develop innovative provider partnerships, and improve the healthcare system. The position includes duties related to identifying and working with providers in both traditional and new payment arrangements, analyzing cost data and trends, implementing initiatives aimed at reducing costs or improving relationships with providers, and helping to refine PEHP’s overall strategic direction for provider contracting. Successful performance of this position requires the achievement of critical contractual objectives while demonstrating the highest degree of professional judgment, interpersonal skills, emotional intelligence, strategic insight, and expertise in data analysis, payment methodologies, and negotiation. ESSENTIAL JOB FUNCTIONS AND DUTIES

Participates in the development and execution of the provider network strategy.

Responsible for the ongoing negotiation and development of PEHP network contracts consistent with the established overall strategies and objectives. Formulates and develops contractual agreements between providers and PEHP. Oversees and/or performs analysis of reimbursement structures/data and coding issues.

Accountable for negotiations, competitive analysis, strategic analysis, and relationships with facilities in the State of Utah and other assigned provider groups; may also be involved in the negotiations of single case agreements as needed.

Works closely with others in the organization to optimize contractual and performance outcomes, including PEHP Legal counsel.

Responsible to be current in understanding the various reimbursement methodologies, including but not limited to resource-based relative value scale (RBRVS), diagnosis-related group (DRG), ambulatory payment classifications (APC), discount from charges, capitation, per diem, and per case methods. Responsible for negotiating and creating contracts that incorporate the various methods of reimbursement.

Participates in the strategy and design of risk-share and population health-based network development, contracting, and evaluation. Regularly meets with providers to review opportunities to better manage member health and costs, to review financial performance and care delivery quality against performance goals.

Meets all team deadlines and responsibilities, serves as a mentor to help other team members maximize potential, helps team members meet goals, promotes a team atmosphere, and provides coaching and training as required.

Provides strategic analysis of provider network opportunities as it relates to growing value-based partnerships, managing network providers, and keeping current with reimbursement methodology changes.

Analyzes and researches complex issues related to PEHP providers and develops solutions within the framework of established guidelines and legal regulations. Designs and recommends changes to programs, contracts, policies, and procedures.

Attends internal meetings as a representative of the Provider Contracting team. Serves as an internal liaison with other departments for education, problem resolution, and communication issues related to provider contracting.

Attends external meetings as a senior representative of PEHP.

Supports fee schedule system maintenance, creation, and implementation processes.

Facilitates changes in provider policies and contracts. Takes the lead in the approval and implementation of the policies and contract changes across all departments within PEHP.

Serves as a representative and liaison between provider organizations and PEHP. Resolves complex problems pertaining to provider claims and contractual terms.

Directs development of preferred provider membership criteria and supports screening of applicants.

Compiles data to be used by PEHP in developing future managed care systems. Tracks historical trends and projections in utilization and health care costs.

Participates in the development, editing, and updating of content and functionality for provider-related web pages.

Oversees the dental provider network including development and management of associated fee schedules.

Maintains strict confidentiality.

Performs other related duties as required.

Provider Contracting Associate ManagerEducation and ExperienceBachelor’s degree required, preference will be given to degrees in health care, communications, or business/management-related fields.Master’s degree (MBA, MHA, MPA, or similar) preferred.Provider Contracting ManagerEducation and ExperienceBachelor’s degree and two (2) years of significant professional experience in provider contracting, negotiation, and network strategy, or an equivalent combination of education and experience.Preference will be given to bachelor’s degrees in health care, communications, or management/business-related fields.Master’s degree (MBA, MHA, MPA, or similar) preferred.Provider Contracting Sr. ManagerEducation and ExperienceBachelor’s degree and four (4) years of significant professional experience in planning and leading provider contracting activities (including relationship management, facility contracting, network development, advanced payment methodologies, and value-based agreements); or an equivalent combination of education and experience.Preference will be given to bachelor’s degrees in health care, communications, or management/business-related fields.Master’s degree (MBA, MHA, MPA, or similar) preferred.Knowledge, Skills, and Abilities (All Positions)This list contains knowledge, skills, and abilities that are typically associated with the job. It is not all-inclusive and may vary from position to position:Required technical skills include the working knowledge and ability of:

Microsoft Office Suite.

Health care coding and information systems.

Required mathematical skills include working knowledge of:

Basic bookkeeping.

Mathematical concepts such as probability and statistical inference.

Must have a working knowledge of:

Various health, dental, and alternative care delivery systems.

Healthcare laws.

Principles of organizational design, supervision, and motivation.

Basic public relations.

Finance of managed care.

Creating and reviewing reimbursement data analysis for competitive pricing/negotiation for provider and facility fee schedules, and future organizational development.

Various healthcare reimbursement methodologies, including but not limited to: DRG, RBRVS, per diems, percent charge discount, per case, APC, capitation, and general Medicare reimbursement methods.

Must possess excellent communication skills:

Communicate effectively verbally and in writing.

Technical writing.

Negotiation techniques.

Understand and clearly communicate to providers:

The principles relative to PEHP’s provider payment vision.

Various medical, dental, and pharmacy claims adjudication policies, procedures, and processes intricacies related to medical, dental, mental health, and chiropractic claims.

Organizational communications.

Interpersonal communications skills.

Various program applications.

Must have the ability to:

Draft technical reports, documents, and agreements.

Analyze a variety of health care issues and make recommendations.

Maintain effective working relationships with professionals, executives, department heads, co-workers, and the public.

Manage multiple projects simultaneously.

Analyze difficult situations, problems, and data.

Use sound judgment in decision making and problem solving.

Follow written and verbal instructions.

Prioritize work.

Perform within deadlines.

Work well in a team environment as well as independently.

Multi-task by handling a variety of duties in a timely and efficient manner.

Follow through with assignments.

Deal effectively with stress caused by workload and time deadlines.

The incumbent must always demonstrate judgment, high integrity, and personal values consistent with the values of URS.Work EnvironmentIncumbent performs in a typical office setting with appropriate climate controls, including extended periods working on a computer. Tasks require a variety of physical activities which do not generally involve muscular strain, but do require activities related to walking, standing, stooping, sitting, reaching, talking, hearing, and seeing. Common eye, hand, finger dexterity required to perform essential functions. Job duties require occasional travel for office business. Individual must be physically capable of safely operating a vehicle, possess a valid license and have an acceptable driving record based upon data provided by a current Department of Motor Vehicle Record (MVR).ID: 2023-3154 External Company URL: http://www.urs.org/ Street: 560 East 200 South Post End Date: 4/17/2023 1:59 AM