Provider Management Consult Sr - 19360AP

WellPoint is the nation's leading health benefits company serving the needs of approximately 28 million medical members nationwide.



Duties and Responsibilities:


Persuades providers to participate in WellPoint networks. Negotiates contract language and rates (i.e., fee schedules, per diems, capitation payment and other reimbursement methodologies) for the delivery of primary and specialty care services.  May participate in negotiations with institutional healthcare facilities, medical groups and/or ancillary services. Re-negotiates with assigned providers for improved rates or terms. Develops and maintains effective business relationships with Central California region. Supports the MBU (Major Business Unit) in marketing, program development/or product implementation through direct interface with provider networks. Works with providers to explain WellPoint products and services, as well as policies and procedures. Keeps abreast of healthcare market place practices related to network services. Works with MBU, Actuary, Case Management, Legal, Information Technology, etc. to address rate proposals, payment structures, resolutions to network provider issues, contract language provisions, tracking and reporting enhancements. Participates with management in conducting network analysis and designing a network that is marketable across the MBUs. Reviews contract proposals from providers. Negotiates hospital, medical and/or ancillary service agreements within financial target guidelines set by the organization. Analyzes new rate schedules and makes recommendations as appropriate. Reviews, analyzes and revises contractual language during negotiations in accordance with organizational policy changes. Monitors healthcare market place and internal utilization trends to assess new opportunities for cost savings, alternate delivery models and financial options. Provides consulting services to MBUs regarding network services needs or enhanced provider relationships.



Requirements and Qualifications:


Has strong knowledge of healthcare operations and network services, including various reimbursement methodologies. 1-2 years network services/contract management experience with good negotiation skills. Strong understanding of healthcare operations and delivery systems to include utilization management. Knowledge of various reimbursement methodologies to include per diems, discounts, capitation, etc. Knowledge of Finance and financial modeling a plus. A Bachelor's Degree or equivalent experience. Experience of contract negotiation in the Healthcare field, proficiency in Access and Excel needed.