Senior Network Representative (remote) - Pittsburgh or Cleveland territory
Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
This position is remote, but must be located within Ohio or Pennsylvania.
The Senior Network Representative is responsible for leading the contracting, negotiations, recruitment/expansion, and education functions within their assigned territories. The Senior Network Representative works closely with their leaders and senior leadership to negotiate high-level language and financial contracting terms to secure large contracts. The Senior Representative completes all high-level provider education, including but not limited to new provider orientations, comprehensive, site, and routine trainings. They review and resolve high-level provider escalated cases to ensure all parties are compliant. This includes, but is 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, including 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.
Job Description
Key Outcomes:
- 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
- Attends 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.
- 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. - Works as liaison for providers and credentialing to ensure delegated agreements are executed
- Partners 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 Access Office Products
- 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 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
This position is not eligible for immigration sponsorship.
We are an equal opportunity/affirmative action employer.
Martin's Point complies with federal and state disability laws and makes reasonable accommodations for applicants and employees with disabilities. If a reasonable accommodation is needed to participate in the job application or interview process, to perform essential job functions, and/or to receive other benefits and privileges of employment, please contact [email protected]
Do you have a question about careers at Martin’s Point Health Care? Contact us at: [email protected]
Skills Required
- Bachelor's degree or equivalent combination of education and experience
- 5+ years experience in provider relations and health care contracting (physician, facility, ancillary)
- Valid driver's license (no restricted or suspended license)
- Proficiency in Microsoft Word, Excel, and Access
- Significant advanced knowledge of managed care contracting and reimbursement methodologies
- Understanding of health plan functions and activities
- Superior verbal and written communication skills
- Strong analytical skills to coach employees and providers on benefits and payment policies
- Strong negotiation skills and experience handling complex contractual obligations
- Ability to make presentations and represent the organization externally
- Ability to work independently and collaboratively; coach/train new staff
- Experience with HEDIS/NCQA requirements and DOD/CMS compliance
- Experience handling escalated provider issue management, payment issues, and balance billing cases
- Ability to develop contract and reimbursement manuals to ensure consistency and accuracy
- Ability to travel with potential overnights at least 50% of the time
What We Do
Martin’s Point Health Care is an innovative not-for-profit health care organization offering high-quality, affordable health care and coverage to the people of Maine and throughout New England. Martin’s Point has seven health care centers in Maine and New Hampshire offering primary and specialty care to those with most major health insurance plans. Martin’s Point also administers two health insurance plans: Generations Advantage—with the only 5-Star Medicare Advantage plans in northern New England, and the US Family Health Plan for active duty military families and retirees throughout most of northern New England and New York. We believe that understanding both the clinical and health plan administrative side gives us the insight we need to make meaningful improvements to the health care system. Martin’s Point is dedicated to creating a community of healthy people through authentic relationships and trust
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