Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:

The Provider Contract Specialist, in conjunction with the Manager of Contracting and Provider Data Management, is responsible for developing, monitoring and managing provider contracts for Medicaid, CHIP and LTSS at

Driscoll Health Plan. Working in collaboration with the Provider Network Strategies, Provider Relations, Information Systems (Epic), and Claims Departments, this position finalizes and implements new contracts as well

as amendments to existing contracts. Responsible for development and management of contract templates, the distribution of provider contracts, coordination and tracking of contract execution, data integrity, provider

communications related to contracts, and storage/tracking of executed contracts, in accord with applicable law.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or Health Plan administration as required.

• Maintains utmost level of confidentiality at all times.

• Adheres to DHS/DHP policies and procedures.

• Demonstrates business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines.

• Coordinates receipt and processing for all provider contracts, delegation agreements, letters of agreement (LOAs), termination notices, extension letters, etc.

• Collaborates in preparation, execution, distribution and tracking of all new or re-contracting agreements for Medicaid, CHIP and LTSS providers.

• Performs basic research to determine the legal names of provider/group/facility, reimbursement method required, as well as the status of the provider/group/facility with TMHP enrollment at time of request.

• Ensures the atypical LTSS providers are enrolled with HHSC at time of enrollment request.

• Performs vetting process to ensure minimum credentialing requirements for unlicensed or uncertified LTSS providers are met prior to contracting.

• Coordinates the issuance of all executed contracts to the appropriate parties with various internal departments such as Credentialing, Network Strategies, Claims, and Tapestry.

• Serves as the liaison for provider contracting, explaining fully the DHP protocols for contracting and responding to questions and/or related issues.

• Assists in analysis and coordination of amendments, reimbursement, and language changes. Requests information of billing codes, services provided and other information needed to complete the contract profile in

collaboration with Manager.

• Collaborate with other departments as well as within own department to research and resolve contractual issues.

• Maintains contracts, including making changes and updates using various systems review contract language, compare and identify changes from current language.

Maintains provider contract tracking system and maintains status logs.

• Manages multiple projects concurrently

• Conducts formal reviews of Contracts and associated documents for compliance with regulatory, accreditation and DHP policy requirements.

• Monitor activities of LTSS providers by tracking the specific terms of each contract and maintaining some mechanism for monitoring and documenting compliance with those terms. Perform special studies/audits, and

EDUCATION AND/OR EXPERIENCE:

- Associate's degree (A. A.) or equivalent from two-year college in a related field.

⎯Bachelor's degree (B. A.) from four-year college or university preferred.

⎯Two years’ experience in health care provider contracting or related contracting experience

⎯Minimum of one-year experience health care provider relations, network management/development, or related work experience within healthcare.

⎯ Prior experience in managed care and LTSS (Long Term Services & Support) preferred coordinates office site visits.

• Develops reports for leadership and senior management related to contract status, content, and other data requested in collaboration with Manager.

• Performs other duties as assigned to facilitate departmental and organizational needs.