At Paramount Health Care, we serve more than 600,000 members across 4 different states. We offer insurance to both large and small groups and cater to Medicare members across Ohio, Michigan, and Indiana. Our Medicaid product (Paramount Advantage) services those living in the state of Ohio. We maintain an accreditation by the NCQA – the National Committee for Quality Assurance – for our Ohio HMO, Elite and Advantage products. We’re a part of ProMedica, which is ranked the second most integrated health system in the U.S. and No. 1 in the Midwest. For more information about Paramount, please visit our website http://www.paramounthealthcare.com.
As a part of ProMedica, Paramount is driven by ProMedica’s mission to improve your health and well-being. ProMedica has been nationally recognized for its advocacy programs and efforts to address social determinants of health. Paramount strives to provide an exceptional experience to every member. For more information about Paramount, please visit our website. http://www.paramounthealthcare.com.
As a member of Paramount’s Value Based team – your work will support our partnerships with Healthcare Providers to:
- Improve healthcare quality/outcomes, focus on preventive care, increase patient satisfaction, and reduce costs.
- Construct arrangements that are focused on team based care models/approaches to better engage/educate patients and improve patient safety.
The Value Based Programs Senior Specialist will work directly with the Manager of Value Based Programs to ensure the success of all existing and future contracts/programs. The Senior Specialist’s primary responsibility is focused on Provider Contracting duties. This position will have responsibilities comprised of three different components; Provider Contracting, Provider Liaison, and Operational/Administrative Coordination. This position will work with a variety of Paramount departments (not limited to; Provider Contracting, Claims, Credentialing, Provider Inquiry, Business Analytics, IT, etc.). This position will also work closely with ProMedica Legal Departments to produce standard/non-standard Value Based contracts as necessary. The Senior Specialist will be responsible for the oversight/monitoring of all Value Based contracts in place. The Senior Specialist will also ensure all Value Based contract templates meet regulatory compliance standards for all applicable state guidelines.
- Prepares and maintains provider contracts. Revises provider contracts as required by local, state, and federal rules and regulations, and Health Plan changes.
- Ensures all terms, including financial terms are administered as required throughout the term of the contracts. Works closely with department staff to design and maintain reports to assure compliance.
- Negotiates reimbursement rates and contract terms and conditions with providers, consistent with management direction. Negotiates modifications to existing contracts.
- Coordinates and/or develops both internal and external communication regarding provider contracting and reimbursement.
- Serves as a resource on policies and procedures related to provider contracting and reimbursement.
- Responsible for accurate documentation of all contractual terms for each agreement.
- Cooperates as needed interdepartmentally as well as intradepartmental, and performs other duties as assigned.
- Assists with training staff on new regulatory and compliance boilerplate language.
- Assist with representing department in steering committees, joint operating committees, participates in STARS/HEDIS workgroups and with NCQA/Regulatory/Compliance meetings.
- Assist department leadership with coordinating and operationalizing staff bi-weekly or monthly meetings.
- Other duties as assigned.
Education: Bachelor’s degree required (Master’s degree preferred) in health care administration, health care related field with minimum of 5+ years’ experience interacting with providers and/or their staff in a management, contracting, or liaison role required.
Skills: Advanced working knowledge of provider/health plan contracting methods and contract negotiation techniques.
- Prefer understanding of provider reimbursement methods regarding professional and facility services. Including advanced knowledge of CPT/HCPCS, EAPG, APC, Revenue Codes, SNF levels of care, and ASC reimbursement methodology.
- Prefer knowledge of health plan operations, claims processing, medical terminology, medical billing, and basic coding methods.
- Demonstrate extensive planning, organizational and problem solving skills required, with the ability to handle multiple tasks.
- 5+ years past experience with analytical methods is preferred.
- Excellent communication (oral and written) skills required.
- Strong facilitation skills required.
- Proficient in use of computers and Microsoft Office applications Excel, Word, and Outlook. Knowledge of Microsoft Access and Power Point is a plus. Knowledge of AMISYS, HealthEdge/Rules Payor, CACTUS, Cognos, IBM/Truven Analytics.
- Ability to move between company workstations and departments required.
- A valid driver’s license and ability to travel independently through Health Plan’s service area could be required.
Years of Experience: Must have a minimum of 5 years in related field
Education: Master’s Degree
Skills: see above
Years of Experience: 7+ Provider Contracting
Personal Protective Equipment:
Physical Demands: Ability to move between company workstations and departments required. Valid driver’s license and ability to travel independently through Health Plan’s service area required. This job requires consistent travel to statewide meetings/forums.
The above list of accountabilities is intended to describe the general nature and level of work performed by the incumbent; it should not be considered exhaustive.
Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status. EOE/M/F/D/V Drug-Free Workplace
ProMedica is a mission-based, not-for-profit integrated healthcare organization headquartered in Toledo, Ohio. For more information, please visit www.promedica.org/about-promedica
Qualified applicants will receive consideration for employment without regard to race, color, national origin, ancestry, religion, sex/gender (including pregnancy), sexual orientation, gender identity or gender expression, age, physical or mental disability, military or protected veteran status, citizenship, familial or marital status, genetics, or any other legally protected category. In compliance with the Americans with Disabilities Act Amendment Act (ADAAA), if you have a disability and would like to request an accommodation in order to apply for a job with ProMedica, please contact email@example.com
Equal Opportunity Employer/Drug-Free Workplace