Independent Health

IT Support

• Provide assistance to pharmacies and internal servicing representatives with pharmacy issues
• Address and resolve issues regarding reimbursement and proper utilization of policies and procedures
• Coordinate resolutions to streamline processes through pharmacy education
• Achieve service levels of 75% (80% for Medicare calls)
• Increase pharmacist satisfaction rates
• Function as a pharmacy advocate
• Assist with entry of prior authorization
• Support pharmacy department projects and assignments
• Assist with training new pharmacy help desk representatives

Pharmacy Help Desk Representative

Contract Specialist

• Develop provider contract agreements and legal documents
• Ensure agreements contain proper language, appropriate lines of business, and correct fee schedules
• Monitor and maintain provider files
• Coordinate contract management and ensure executed contracts and amendments are current, compliant, and completed on time
• Identify and analyze information supporting contract negotiations
• Prepare information for contracts, amendments, letters of agreement, and other binding documents
• Represent Network Contract Management in compliance requirements and regulatory adherence initiatives
• Interpret and compile CMS, DOH, and internal audit information requests and develop responses
• Peer review Network Provider documentation and ensure outstanding information is received
• Process provider requests, conduct provider outreach, and respond to contract and fee schedule inquiries
• Develop the Network Provider network through needs identification, outreach, relationship-building, and collaboration
• Coordinate contract implementation, analytics, operational tasks, and provider servicing
• Ensure provider contract-related payments and incentives are timely and accurate
• Collaborate with Family Choice of WNY on skilled nursing facility strategies, contractual arrangements, fee schedules, network maintenance, and facility relationships
• Create department reference tools, tip sheets, and standard operating procedures
• Collaborate with Credentialing, Legal, Provider Network Administration, Reimbursement, Utilization Management, Finance, Claims, Servicing, and other teams
• Participate on cross-functional teams
• Support strategic and corporate goals of management and senior leadership

Senior Network Contract Specialist

Medical Director

• Assist the Medical Director in overseeing Utilization Management (UM) programs
• Support the development and maintenance of UM programs, focusing on clinical accuracy and appropriateness
• Assist in developing strategic corporate direction and focus for UM programs
• Support the SVP, Healthcare Services in preparing annual UM program metrics
• Contribute to measurable outcomes for prior authorization, step therapy, and quantity limit programs
• Collaborate with internal teams on corporate HEDIS initiatives and clinical program development
• Provide clinical guidance and oversight to clinical program development teams, clinical service operations, and clinical quality committees
• Serve on Independent Health committees as directed by the Medical Director
• Ensure UM decisions comply with member contracts, medical necessity requirements, approved policies, and regulatory requirements
• Ensure appropriate information is available to determine medical necessity
• Ensure reviews are completed within regulatory time frames
• Work with UM leadership to ensure process accuracy, consistency, and efficiency
• Assist UM leadership with performance reporting
• Support improvements to clinical service operations

Associate Medical Director – UM

Procurement

• Coordinate the overall contracting strategy on a cross-functional basis with Health Care Services, Finance, System Configuration, Product Development and Network Contract Management
• Manage and lead negotiation, reimbursement development, analytics, contracting and operational aspects of facility health care provider contracts
• Lead staff in the development and risk assessment of reimbursement methodologies
• Manage contracting issues for all facility provider contracts, including contracts, rate amendments and addendums
• Collaborate with organizational leaders to ensure facility rate agreements are accurately and efficiently implemented
• Manage operational and relationship issues with hospitals, free-standing ambulatory surgery centers, skilled nursing facilities and other ancillary providers
• Develop strategic compensation and contracting strategy with facility providers
• Serve as a lead contract negotiator under the direction of the Chief Financial Officer or designee
• Research and develop reimbursement methodologies for facility providers
• Identify emerging reimbursement trends from government and private payers
• Lead integration of reimbursement methods within system configurations, fee schedules, claims processing attributes and provider contracts
• Make recommendations and present results to the Chief Financial Officer, designee and Executive Team
• Manage network reimbursement, analytical, operational and contracting staff
• Train staff on reimbursement, analytics, contractual, operational and relationship issues

Pharmacy Help Desk Representative

Senior Network Contract Specialist

Associate Medical Director – UM

Director – Network Contract Management