Provider Network Development Specialist

Doctors HealthCare Plans, Inc.; Miami (FL); On-site; USD 90,000 - 120,000; Full time

Job summary

Doctors HealthCare Plans, Inc. in South Florida seeks a Network Development professional to build, administer and expand the provider network, negotiating physician, medical group, ancillary, hospital and vendor agreements.

You will ensure contracts meet state and federal guidelines and coordinate credentialing across providers. The role involves negotiating provider agreements, maintaining data accuracy, and performing analyses to support network growth.

Qualifications

• Bachelor’s degree in health services administration, business or related field.
• Excellent negotiation and communication skills.
• Knowledge of Medicare Advantage operational and regulatory guidelines.
• Ability to travel regularly within the Miami/Dade region.
• Experience with provider contracts and data management is preferred.

Responsibilities

• Ensure contract language complies with State, CMS, AHCA, and regulatory guidelines.
• Use only company approved Provider Agreements.
• Obtain credential information for new providers and facilities.
• Ensure completeness of all information in agreements.
• Negotiate Provider Agreements for physician, medical, ancillary and hospital services.
• Negotiate amendments to contracts.
• Maintain provider data base system integrity related to contracts.
• Perform claims and utilization research for re-contracting providers.
• Conduct comparative analysis of potential providers.
• Support departmental projects as requested by VP Network Development or President/CEO.

Skills

Excellent negotiation skills

Excellent oral and written to?mb ...

Education

Bachelor’s degree in health services administration, business or related field

Job description

Job Purpose:

This position is responsible, in the South Florida region, for all activities related to developing, maintaining and expanding the network of providers, including development, administration and negotiation of physician, medical group, ancillary, hospital and vendor agreements in compliance with all regulatory state and federal guidelines.

Responsibilities:

• Responsible for ensuring that the language of all contracts is in compliance with all State, CMS, AHCA, and any other regulatory agency.


• Responsible for utilizing only company approved Provider Agreements.


• Responsible for obtaining all credential information for new providers and facilities and ensure completeness and current information is provided.


• Responsible for ensuring completeness of all information in the agreements.


• Responsible for negotiating Provider Agreements for Primary Care Physician Services, Medical Specialty Care Services, Ancillary Care Services and Hospital Services.


• Responsible for negotiation of agreements for all providers.


• Performs analysis to determine the needs of the existing networks


• Determining the forms of payment, i.e., capitation, FFS or trade agreements depending on financial parameters established by the Network Development Department.


• Responsible for negotiating amendments to contracts


• Responsible for assisting in maintaining the integrity of the provider data base system as it relates to contracts.


• Responsible for performing claims and utilization research for re contracting existing network providers


• Comparative analysis of potential providers.


• Responsible for departmental projects as requested and needed.


• Performs other job related duties as assigned from time to time by the VP Network Development and/or President/CEO

Qualifications:

• Excellent negotiation skills


• Excellent oral and written communication skills


• Requires regular travel between locations in the Miami/Dade region


• Bilingual English/Spanish preferred


• Bachelor’s degree in health services administration, business or related field of study or an equivalent combination of training and experience.


• Demonstrates a broad-scope of financial knowledge


• Knowledge of current Medicare Advantage operational and regulatory guidelines established by CMS, AHCA and other federal and state regulatory guidelines


• Excellent organizational and customer skills


• Versatility


• Excellent customer skills


• Ability to work well under pressure and difficult situations


• Capable of managing a variety of complex issues while driving momentum of key initiatives


• Excellent knowledge and management of risk relationships

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.