Contractor and Network Development Specialist

Lancaster, PA
Position Description:

Summary: Contracting and Network Development Specialist reports to the Senior Director of Contracting and Network Development (Sr. Director) with dotted line to the President/CEO. This position has primary responsibility for facilitating the relationships between each Kairos Member facility and each managed care organization (MCO) or other Health Plans and networks (ACO, etc.). This position maintains and enhances all Managed Care contracts and initiates and maintains contacts within the Health Plans to optimize contract negotiation, obtain the best contract terms possible, support of positive patient outcomes, and optimal payment resolution. This position creates the design, implementation and administration of provider payment methodologies that align the incentives of Kairos facilities with the various Health Plans’ to provide outcomes based, cost effective healthcare for patients/residents.

This position acts as teacher, advisor and facilitator for the Kairos member facilities as it relates to these Health Plans. He/She/They conducts intensive training sessions both in groups and individually on methods to gain positive outcomes when interacting with Health Plans. Acting as a consultant, advocate, resource, and liaison with assigned Health Plans, this position assures that proper process is followed and proper payment is received for all managed care patient/resident encounters. This position will provide support to Kairos facilities on a variety of topics including: the authorization/referral process, documentation requirements, care management, concurrent review, proper billing procedures, appeals, payer policy and procedure, quality incentives, cost assessment, program advancement, value-based initiatives, etc.

This position will use data matrices and assist in continuous development of data sources to support positive outcomes to members. He/She/They will collaborate with the Senior Director of Contracting and Network Development and the President/CEO in maintaining and enhancing all MCO contacts and contracts. This position will include support of the Member Services Representative responsibilities to ensure continuous improvement and accuracy with current payer matters (including credentialing, website content, admission and claim procedures and issues, education, etc.).

The position also serves the dual function of in-system consultant through EXPERTLINKS/Consulting services. He/She/They identifies needs and opportunities within the system and presents facilities with proposals for financial, clinical or operational solutions and other Group Purchasing (GPO)/Expertlinks (EL)/Consulting engagements to enhance outcomes and quality of care.

The Contractor and Network Development Specialist delivers friendly, superior, and enthusiastic customer service. He/She/They provides prompt and accurate service with a goal toward constantly improving outcomes.

Essential Duties

The duties of the contractor/network developer will include but not be limited to the following:

  • Maintain a thorough knowledge of all aspects of payers’ strategies, policies, procedures, quality measures, facility services and community/public status; and utilize this information to improve the referrals and reimbursement status of the Kairos members.
  • Provide extraordinary customer service with members, payer relationships and with external contacts by exceeding expectations, providing effective and complete communication and creating positive resolutions.
  • Continuously improve member, payer relationships through regular and essential communication. Be proactive in creating opportunities for members and in generating positive solutions on both member and payer’s behalf.
  • Develop and update training modules on managing and utilizing the information and relationship with health care plans. Also, develop, maintain and enhance materials appropriate to the role of health plan educator/mediator. This may include such items as manuals, handouts, articles, graphs, charts and presentations.
  • Visit each assigned Kairos facility as needed, with a minimum of one time annually. Utilize other forms of communication to assess member’s payer needs, evaluate member services and processes and evaluate all functions and educational needs related to managed care and reimbursement. Develop solutions to meet these identified needs.
  • Develop and maintain relationships with key individuals at each health plan associated with Kairos facilities through written, phone and face-to-face communications to improve the Kairos facilities’ positions in contract negotiation and in payment/process challenges. Build payer relationships that create payer loyalty and a competitive advantage for Kairos in the marketplace.
  • Through data reporting and face-to-face, phone and written communication; advocate for the capabilities and services available at each Kairos facility. Utilize quality and performance metrics and benchmarking for internal analysis, creating leverage in alternative payment models and focusing capabilities to work in new markets focused on outcomes-based healthcare.
  • Assess and compile data (Avalere, etc.) to assist or support members in analyzing their market and operational positions.
  • Maintain a thorough knowledge of all aspects of payers’ policies, procedures, and strategies; and routinely update and share this information with the Kairos members. Identifying and directing these changes with Kairos team and membership.
  • Continually maintain and enhance all payer contracts. Ensure that all payer contracts are current to member needs. Communicate these member needs effectively and timely to generate positive contract outcomes.
  • Provide and obtain second eyes contract review for every contract negotiated by Kairos.
  • Act as mediator, member advocate and troubleshooter in all disputes with Health Plans.
  • Continually discover, establish, work for, and deliver positive results for the Kairos organization. Assist the President/CEO in safeguarding the credibility, reliability and trust of the Kairos reputation.
  • Maintain and enhance all payer contacts and contracts.
  • Provide support for the growth of positive payer initiatives within the Kairos Health System. Act as a liaison between the Kairos facilities and these programs to insure positive outcomes.
  • Utilize CRM and the Database for accounts, contacts, agreements, tasks, opportunities, data sources, reporting, etc. to best manage and monitor operations, goals and results.
  • Assess, compile and deliver data (Avalere, PPN, etc.) to assist or support members in analyzing their positions.
  • Work with Sr. Director to develop a contracting resource group of members, payers, and other sources to address current issues and trends to better position Kairos regarding payment solutions for long-term care services.
  • Assist in developing and managing Kairos Member Preferred Provider Networks. This will include sharing payors’ strategies, contract terms, and Member education needs with a goal of ensuring successful evolution in the evidence-based programs, clinical models, aligned payment incentives and other opportunities.
  • Understand and create value propositions for Members that explain the long-term value of payment innovation programs.
  • Understand and negotiate payment rates for payment innovation programs.
  • Read, interpret, and apply policies, procedures, medical terminology, laws and regulations related to services provided to residents.
  • Comply with all required laws and regulation relating to duties and responsibilities.
  • Understand Payer contracts that define terms and conditions related to payment innovation programs and ensure risk mitigation for alternative payment methodologies.
  • Manage the implementation and administration of alternative payment methodologies within Kairos, to include but not limited to: capitation, bundled payments, pay-for-performance programs, patient centered medical home programs, and shared risk arrangements.
  • Improve provider network efficiencies through the identification of cost and quality outliers and the establishment of interventions designed to improve performance.
  • Research payment innovations in both the local and national markets and prepare summaries on emerging trends and effectiveness of alternatives to fee for service payments
  • Support any Kairos marketing and branding efforts as needed. This includes member growth and promotion of consulting services
  • Participate, as directed, in special and routine projects
  • Participate, as needed, in the planning and operation of the Kairos Conference and Exhibit
  • Provide phone coverage with other staff during office hours.
  • Cover for Member Services Representative when needed
  • Participate in consulting engagements as is appropriate
  • Perform other duties as may be requested.
Required Qualifications:

Physical & Functional Requirements and Working Conditions:

  • Maximum visual and communication ability is required
  • Position requires ability to verbally present to individuals, in group meetings, and extensive phone calls
  • Manual dexterity to use personal computers is required
  • This position requires sitting, standing, and walking
  • Sitting at a desk is required for computer utilization, writing, and data analysis
  • Stooping and bending when using files
  • Walking to meetings is required at various locations across the Kairos region
  • Individual must also be able to drive to meetings in the Kairos region on a regular basis to meet with clients
  • Ability to lift or carry up to 50lbs.
  • Problem solving
  • General learning ability

Technical and Professional Qualifications

The Contractor and Network Development Specialist shall possess the following technical and professional attributes:

  • Knowledge of Systems and methods used to measure clinical and cost performance
  • Ability to persuade Members of the value proposition of innovative payment programs
  • Experienced professional with some billing and financial background
  • Strong working knowledge of managed healthcare and ability to manage key insurance payer relationships
  • Ability to effectively negotiate and implement contracts for services related to skilled nursing, outpatient, home health, hospice and LIFE/PACE providers
  • Understanding of Medicare and Medicaid coverage for post-acute and long-term care
  • Familiarity with skilled nursing and post-acute care regulation and environment
  • Strong written and oral communication skills; strong listening skills. Strong writing skills. An excellent communicator.
  • Ability to work independently, to be innovative and assume responsibility for projects and tasks
  • Characteristics of a high-performance team member
  • Diplomatic yet assertive
  • Effective time management skills
  • Strong service focus and customer service skills. Ability to meet and exceed the needs of the customer at all times
  • Strong project management abilities
  • Ability to prepare proposals
  • Strong track record in training and staff development
  • Proficiency with Microsoft office suite, Access, basic webpage operation, and CRM. Ability to build report concepts to meet organizational needs
  • Team builder committed to achieving common goals and objectives
  • Willingness to travel throughout our membership area. Other travel on occasion
Desired Qualifications:
Contact Information:
Kairos Health Systems
Lancaster PA

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