Summary Establishes and maintains provider networks for assigned lines of business. Serves as main contact for all recruiting or recontracting efforts and all contract questions or issues that arise with providers. Recommends and implements cost-effective strategies while delivering high quality products to customers.Description
- 40% Conducts initial/renewal contract negotiations with providers. Performs detailed financial analysis and modeling of provider contract proposals to determine financial impact of various pricing/contract decisions. Influence provider behavior by means of education, utilization analysis and presentation of provider performance. Ensures contract obligations are met. Directs/coordinates credentialing process for provider networks.
- 25% Monitors performance to ensure contract compliance by internal departments/medical providers. Reviews/audits data compiled by subcontractors in accordance with the Center for Medicare and Medicaid services (CMS) regulations. Assists with impact analysis of pricing decisions regarding negotiated payment rates for network providers.
- 20% Develops/maintains effective working relationships with providers, government agencies, internal departments, and other customers. Ensures responses are given in a timely manner to all inquiries.
- 10% Maintains working knowledge of current and proposed regulations of state and federal laws and the latest trends in healthcare technology and financing. Evaluates and communicates any pertinent changes to management.
- 5% Assists in the development of training programs and materials for internal staff. Participates in special projects to improve external and internal processes.
- Masters Degree in Health Care Administration, Public Administration, or Business Administration
Required Work Experience:
- Five years provider network management experience.
Preferred Work Experience:
- At least two years in Dental Network Management or Sales with an understanding of the dental Market in South Carolina and dental benefit structures.
Required Skills and Abilities:
- Ability to develop/maintain effective business relationships with providers, and representatives.
- Excellent verbal and written communication skills.
- Excellent presentation and project management skills.
- Excellent analytical and critical thinking skills.
- Ability to handle confidential or sensitive information with discretion.
- Demonstrated knowledge of managed care contract negotiations.
Preferred Skills and Abilities:
- General knowledge of dental provider billing/accounting systems including electronic claims filing.
Required Software and Other Tools:
- Microsoft Office Suite.
- Working knowledge of reimbursement systems.
- Typical office environment.
- Travel required.
We participate in E-Verify and comply with the Pay Transparency Nondiscrimination Provision. We are an Equal Opportunity Employer. Equal Employment Opportunity Statement
BlueCross BlueShield of South Carolina and our subsidiary companies maintain a continuing policy of nondiscrimination in employment to promote employment opportunities for persons regardless of age, race, color, national origin, sex, religion, veteran status, disability, weight, sexual orientation, gender identity, genetic information or any other legally protected status. Additionally, as a federal contractor, the company maintains Affirmative Action programs to promote employment opportunities for minorities, females, disabled individuals and veterans. It is our policy to provide equal opportunities in all phases of the employment process and to comply with applicable federal, state and local laws and regulations.
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