Under minimal supervision, the Director of Provider Relations and Contracting will implement provider relationship and contract strategies across all Managed Care plans. (Commercial, Medicare, Child Health Plan Plus, Exchange and Medicaid). The Director of Contracts/Provider Relations will Analyze, Negotiate and execute Multi-Million Dollar contracts with Rental Networks Hospitals, Physician Groups, and Primary Care Physicians, Specialty Care Physicians, Ancillary Providers and other individual health care providers across all Managed Care Initiatives. Such agreements may include discounts, capitation, bundled payments and risk sharing. Manage and direct a team of provider representatives in order to maintain Provider File and Provider Contract data across Large Hospitals, Physician Groups, and other Health Care Related Providers. Manage and direct a team of provider relations call center representatives in order to meet the customer service needs of Managed Care Providers and other Health Care Entities. Manage and direct Provider Relations Data Base Technicians in order to manage the proper uploading, adjudication and pricing of Electronic and paper claims received by Managed Care through the Claims Adjudication System. Manage and direct the Provider Relations staff in order to properly test, new benefit designs, Medicare Fee Schedules, Medicaid Fee Schedules, RBRVs Fee Schedules, Procedure Code Sets, and ICD-9 Diagnosis Code Sets for configuration to the Claims Adjudication System. Manage and direct the Provider Relations Claims Specialist in order to ensure that Provider Re-submissions, Re-considerations and Appeals are properly processed. Responsible for development/maintenance of provider portal.
Minimum Qualifications: Education: Bachelor's degree in healthcare administration,business administration, or related fields (preferred) and a minimum of 5 years experience analyzing, negotiating and executing healthcare contracts.
Experience: Typically five years of experience in software applications support and with information systems related to Managed Care. Extensive experience with Medicare, Medicaid and Commercial Fee Schedules. Minimum of five years supervisory experience and analyzing, negotiating and executing health care contracts.
Knowledge, Skills & Abilities: Extensive experience with ICD-9, CPT, HCPC and other coding systems used in conjunction with health care services. In depth knowledge of the Medicare, Medicaid and commercial fee for service schedules. General understanding of CMS and DOI rules and regulations related to contract execution. Required skills include collecting and compiling data in order to provide detailed analysis of Health Care cost trends across all Managed Care Initiatives. Must be able to work independently and as part of a team. Ability to organize and direct a department across multiple functions. Knowledge of NCQA requirements related to contracting and provider services.
Certificate/License/Registration: Active Colorado Driver’s license All Certifications and Licenses required for this job must be kept current as a condition of continued employment.
All job applicants for safety-sensitive positions must pass a pre-employment drug test, once a conditional offer of employment has been made.
Internal Number: 52186
About Denver Health Hospital Authority
Denver Health is an integrated, efficient, high-quality academic health care system that is considered a model for the nation. The Denver Health system includes the Rocky Mountain Regional Level I Trauma Center, a 525-bed acute care medical center, Denver’s 911 emergency medical response system, 8 family health centers, 15 school-based health centers, the Rocky Mountain Poison and Drug Center, the Denver Public Health Department, an HMO, and The Denver Health Foundation.
As Colorado’s primary safety net institution, Denver Health is a mission-driven organization that has provided more than $3.3 billion in care for the uninsured in the last ten years. Denver Health is a leader in performance and quality improvements and remains financially secure, in part, due to its nationally recognized implementation of lean principles in healthcare. Denver Health is a major resource to the community, serving approximately 185,000 individuals and 67,000 children a year.
Located just south of downtown Denver, Denver Health is just minutes away from many of the cultural and recreational activities Denver has to offer.
We strongly support diversity in the workforce and Denver Health is an ...equal opportunity employer (EOE).
“Denver Health is committed to provide equal treatment and equal employment opportunities to all applicants and employees. Denver Health is an Equal Opportunity Employer and does not discriminate against any employee or applicant for employment because of race, color, sex, age, national origin, religion, sexual orientation, gender identity, status as a veteran, and basis of disability or any other federal, state or local protected class.”