Especialista Senior De Contratación
Regular
Exempt
GENERAL DESCRIPTION:
Coordinates visits, participates in contracts, and collaborates on negotiating financial agreements for the company’s Provider Network. Analyzes financial impact reports to recommend contracting models and ensures that the coding of contracted services is adjustable and complies with company policies and procedures. Executes processes related to provider contracting, including market analysis, utilization reports, site visits, and contracting processes following the company’s Contracting Policy. Monitors and manages the performance and compliance of contract initiatives. Provides guidance and mentorship to other department staff members.
ESSENTIAL FUNCTIONS:
- Oversee the negotiation and execution of high-value, complex, and high-risk provider new contracts, as well as the renewal and termination of providers, following the established formal process.
- Develop, review, and approve draft contracts to ensure compliance with organizational policies and regulatory requirements.
- Serve as the primary point of contact for key vendors, clients, or partners during critical negotiations, acting as the intermediary between the specialists and the department management team when necessary.
- Maintain an updated record and monitor the progress and status of contract requests according to the established provider renewal schedule and follow up until the process is completed within the designated period for all lines of business.
- Designs, prepares, and analyzes complex reports to facilitate provider determinations and negotiation strategies, including the evaluation of the company's proprietary fee schedules, internal claims data, the Center for Medicare and Medicaid Services (CMS) fee schedules, Medicaid fee schedules for Puerto Rico, actuarial benchmarking reports, hospital cost reports, and contracted provider agreements, as applicable.
- Develop and maintain effective business relationships with providers, ensuring they understand the contract's structure, specifications, history, and available resolution alternatives and agreements.
- Participate in establishing negotiation terms, ensuring that rates are accurately included in contracts and approved by the designated authority after undergoing an economic impact analysis. Ensure that these terms are configured correctly in the internal application and comply with billing guidelines, as well as meet the Credentialing requirements review.
- Oversees contracting initiatives to ensure the corresponding economic impact results.
- Collaborate with other departments and levels of authority to resolve issues related to provider contracting and coordinate the approval process for new contracts, renewals, and amendments before sending the approved agreements to the providers.
- Analyze and partner with other departments to resolve complex situations, referring sensitive issues to management as necessary.
- Visits providers' facilities to audit the compliance with the requirements established by company policies and procedures, as well as State and Federal Laws, for the provision of the service they are interested in contracting or renewing.
- Provide guidance, training, and mentorship to the unit Specialists and Coordinators.
- Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
- May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS
Education and Experience: Bachelor’s Degree in Business Administration or related areas. At least four (4) years of experience in negotiation processes and/or provider contracting agreements in the Health Industry. Experience in creating and using financial projection tools and spreadsheets, interpreting, and reviewing financial projections and models to assess financial impact, in contracting changes, and new contracts execution is preferred.
“Proven experience may be replaced by previously established requirements.”
Certifications/Licenses: A valid driver's license in the Commonwealth of Puerto Rico is required.
Other: Car in good condition and available to travel to different locations in Puerto Rico. Knowledge related to healthcare coding compliance is preferred. Knowledge of contracting and negotiation in the Healthcare Industry. Knowledge of contracting models such as APC, DRG, Capitation, ASC, Fee for Service, and Case Rate, among others. Knowledge of the relationship between medical plans, providers, and referral sources.
Languages:
English – Advanced (comprehensive, writing and verbal)
Spanish – Advanced (comprehensive, writing and verbal)
“We are an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities.”
