About us:

Fallon Health is a company that cares. We prioritize our members-always-making sure they get the care they need and deserve. Founded in 1977 in Worcester, Massachusetts, Fallon Health delivers equitable, high-quality, coordinated care and is continually rated among the nation's top health plans for member experience, service, and clinical quality. We believe our individual differences, life experiences, knowledge, self-expression, and unique capabilities allow us to better serve our members. We embrace and encourage differences in age, race, ethnicity, gender identity and expression, physical and mental ability, sexual orientation, socio-economic status, and other characteristics that make people unique. Today, guided by our mission of improving health and inspiring hope, we strive to be the leading provider of government-sponsored health insurance programs-including Medicare, Medicaid, and PACE (Program of All-Inclusive Care for the Elderly)- in the region. Learn more at fallonhealth.org or follow us on Facebook, Twitter and LinkedIn.

Summary:

Responsible for the analysis, negotiation/renegotiation, implementation, readjustment, evaluation, and continuous improvement of all functions of provider contracting. Manages financial and operational issues related to contractual provider arrangements. Responds to both internal and external customers regarding provider contractual arrangements, both for contract implementation and ongoing operations.

Negotiates, develops and designs contractual provider arrangements including language and pricing methodologies.
• Evaluates contractual payment methodologies in order to determine financial risk to insurer and provider (per diem, capitation, discount from charge, DRG, case rate, bundled payments, pay for performance programs , etc.). Ensures the design, production, and distribution of site financial, utilization and member information; ensures the production and completeness of annual site settlement reports. Interfaces between the Plan's Finance department and individual sites for budget, financial reporting and settlement arrangements for all relevant products.
• Performs quantitative analyses of various financial and clinical data in order to evaluate multiple contracting options. Reports performance of ongoing contractual arrangements to appropriate parties.
• Manages, coordinates and resolves operational issues related to specific areas of responsibility. Serves as contact person for internal departments (i.e. Claims, Finance, Care Management Services, Patient Relations, Marketing, Credentialing, Provider Relations, etc.).
• Researches, analyzes and presents recommendations to Senior Director regarding contractual and financial decisions.
• Manages provider correspondence relating to contracts and responds to requests from potential new providers for FCHP.
• Maintains computerized tracking system for new and revised agreements. Coordinates and communicates contractual information to appropriate departments within FCHP.
• Maintains assigned provider network; physician, hospital, ancillary, and/or carve out vendor as assigned by Senior Director or Manager.
• Prepares, updates and maintains files and database for all assigned provider contracts.
• Serves as committee member in cross-functional teams as assigned by Senior Director.
• Assists in Provider Relations activities including servicing, educating and distributing information to contracted providers.
• Analyzes and presents financial reports to providers. Makes recommendations to providers regarding quality and cost improvements.

Education:

Bachelor's degree or equivalent experience required. Master's degree in Business Administration, Healthcare Administration, or Public Health preferred. Previous background in nursing or any allied health field is often valuable but not required.

Experience:

Minimum of three years experience in managed healthcare environment(s) with related work in provider contracting, healthcare finance, provider reporting/profiling, and/or provider relations. Experience in provider contract negotiations, including FFS, capitation models, and pay for performance models is preferred. Excellent analytical, strategic thinking, and creative thinking skills are required. Superior verbal and written skills, excellent computer skills (Word, Excel, Access) are essential to this position.

Fallon Health provides equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

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