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Memorial Hermann Health System

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Health Solutions

Contracting Manager, Health Plan

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Location 929 Gessner Road,Houston,TX 77024 Facility Memorial Hermann Tower Category Health Solutions Type Full time Requisition 100079223

At Memorial Hermann, we’re about creating exceptional experiences for both our patients and our employees. Our goal is to provide opportunities for our diverse employee population that develop and grow careers in a team-oriented environment focused on patient care.

Every employee, at every level, begins their journey at Memorial Hermann learning about the history of the organization and its established culture built on trust and integrity. Our employees drive this culture, and we want you to be a part of it.

Job Summary

Position responsible for managing the provider maintenance operations staff. This includes monitoring all aspects of production to ensure timeliness and accuracy in the capture of demographics and contracts related to brokers, offices, providers, and vendors as well as contract fee schedules. The position will also monitor and appraise employee performance and communicate to employees accordingly.

Job Description

Minimum Qualifications:

  • Education: Bachelor’s degree in Business or related field required. In lieu of degree, 4 years experience in an insurance company or managed care environment.
  • Experience: Minimum of two to three years in a leadership role within a provider maintenance, credentialing, or network development area in a managed care environment (such as an HMO, TPA, or related insurance company).
  • Knowledgeable and compliant with all relevant laws, rules regulations and accreditation standards and requirement. Working knowledge of regulation regarding provider networks and contracting (State Department of Insurance, ERISA, etc.).
  • Conversant with national standard coding (CPT, HCPCS, ICD, DRG, place of service codes, modifiers, revenue codes, etc.).
  • Conversant with various reimbursement methodologies related to service type, provider type, coding, etc.
  • Familiarity with provider network arrangements and the impact to claims processing, reimbursements, benefit levels, etc.
  • Proficient computer skills, specifically with Microsoft Office and Windows.
  • Strong analytical and research abilities to triage issues, perform reconciliations or analyses of claims or provider data, and audit processed work as needed. Ability to interact with various external entities such as health care providers, regulators, clients, and brokers, etc.
  • Demonstrates commitment to the Partners-in-Caring process by integrating our culture in all internal and external customer interactions; delivers on our brand promise of “we advance health” through innovation, accountability, empowerment, collaboration, compassion and results while ensuring one Memorial Hermann.

Principle Accountabilities:

  • Manage all provider maintenance operations staff reporting to this position and remain available at all times for questions.
  • Develop and motivate subordinates, establish teamwork, and build employee morale.
  • Monitor all aspects of production to ensure timeliness and accuracy in the capture of demographics and contracts related to brokers, offices, providers, and vendors.
  • Create action plans based on observations to drive process improvement.
  • Monitor inventory levels of provider change requests and implement inventory control process system needed to ensure maximum production at all times.
  • Maintain fee schedule data per contractual and regulatory requirements.
  • Prepare and submit production reports to management as required.
  • Perform network disruption analyses or network adequacy audits upon request.
  • Develop and maintain departmental policies and procedures and desktop procedures according to current business needs as well as industry and regulatory requirements. Interface with all internal and external customers in a respectful and responsible manner to enhance relationships and minimize conflicts as validated by complaints, feedback, and management observation.
  • Accountable for Quality initiatives within department and performs at least 30% of time spent on job functions supporting quality improvement (audits, training, coaching, assessment of workflows and process etc.) quarterly.
  • Communicate, collaborate and cooperate with internal and external stakeholders.
  • Adhere to all Compliance/Program Integrity requirements.
  • Comply with HIPAA Regulations Ensures safe care to patients, staff and visitors; adheres to all Memorial Hermann policies, procedures, and standards within budgetary specifications including time management, supply management, productivity and quality of service.
  • Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency; supports department-based goals which contribute to the success of the organization; serves as preceptor, mentor and resource to less experienced staff.
  • Other duties as assigned.

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