Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
' Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
' Children's Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
' Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
' Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
JOB SUMMARY
The Provider Contracts Manager at Community Health Choice is responsible for network development and management. This role involves expanding provider networks for existing and new lines of business, negotiating provider agreements, ensuring regulatory compliance, and maintaining effective relationships with providers. The Provider Contracts Manager collaborates with various internal departments to achieve departmental goals and contribute to the overall success of the organization.
JOB SPECIFICATIONS AND CORE COMPETENCIES
Negotiate Provider Contracts:
Negotiate contract language and rates with hospital, physician, ancillary, and LTSS providers in accordance with established parameters and guidelines.
Collaborate with Compliance, Legal, and Credentialing teams to finalize
provider contracts, including amendments and new agreements.
Ensure compliance with regulatory and product requirements related to provider contracting, including network adequacy standards.
Expand Provider Networks:
Actively seek opportunities to expand provider networks for existing and new lines of business.
Conduct external meetings with prospective and existing providers to negotiate
or renegotiate agreements.
Collaborate with other relevant teams to facilitate network expansion efforts.
Ensure Compliance and Network Adequacy:
Assure compliance with regulatory requirements and product specifications related to provider contracting functions.
Monitor and ensure network adequacy, making necessary adjustments to meet
regulatory standards.
Coordinate with Network Management, Claims, and Provider Data Integrity teams to ensure accurate contract reimbursement and adherence to requirements.
Contribute to Departmental Goals:
Actively contribute to the achievement of departmental goals as outlined in the annual business plan.
Participate in departmental process improvement initiatives to enhance
operational efficiency and effectiveness.
Provider Relationship Management:
Serve as a liaison between Community Health Choice and its providers, facilitating communication and addressing any issues that arise.
Resolve problems and ensure smooth operations by maintaining positive
relationships with providers.
Other Duties:
Perform other duties as assigned to support the overall functioning of the department.
QUALIFICATIONS:
Education/Specialized Training/Licensure: Bachelor's degree Or
7 years' experience in lieu of degree (Must be the equivalent combination of required education and minimum experience.) required.
Work Experience (Years and Area): Minimum of three (3) years of experience in healthcare, providers/managed care, contracting, and relations with degree.
Minimum of seven (7) years of experience in healthcare, providers/managed care, contracting, and relations without degree.
Management Experience (Years and Area): N/A
Software Proficiencies: Microsoft Office (Word, Excel, Outlook)
Other: Travel will be required 50% of the time. Must have a vehicle and a valid State of Texas Driver's License. Must have managed care contract negotiation experience, preferably in the Houston market. Experience with Star Plus, LTSS, HCBPs, and
Medicare products is a plus.
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