Provider Contract Specialist - Commuity Health Choice
Community Health Choice, Inc. (Community) is a non-profit managed care organization (MCO), licensed by the Texas Department of Insurance. Through its network of more than 10,000 providers and 94 hospitals, Community serves over 400,000 Members with the following programs:
• Medicaid State of Texas Access Reform (STAR) program for low-income children and pregnant women
• Children’s Health Insurance Program (CHIP) for the children of low-income parents, which includes CHIP Perinatal benefits for unborn children of pregnant women who do not qualify for Medicaid STAR
• Health Insurance Marketplace Plans that offer individual health coverage that includes preventive care, emergency services, prescription drugs, and hospitalization available to all, regardless of pre-existing conditions.
• Community Health Choice (HMO D-SNP), a Medicare Advantage Dual Special Needs plan for people with both Medicare and Medicaid that combines Medicare Part A and Part B benefits, Medicare Part D prescription drug coverage, and Medicaid benefits with additional health benefits like dental, vision, transportation, and more.
Improving Members' experiences is at the heart of every Community position. We strive every day to make sure that our Members have access to the high-quality health care they need and deserve.
Community is accredited by URAC for its health plan operations. We offer care management programs for asthma, diabetes, and high-risk pregnancy. An affiliate of the Harris Health System (Harris Health), Community is financially self-sufficient and receives no financial support from Harris Health or from Harris County taxpayers.
Skills / Requirements
JOB SUMMARY: Responsible for network development; negotiating, monitoring and managing the contractual
relationship of assigned provider contracts. Working in coordination with Compliance, Provider Relations and Network
Management, negotiates and finalizes provider contract language and rates, including amendments for existing
contracts and establishment of new ones. Contracts for physician, hospital, ancillary and delegation of services for
Medicaid and any other programs CHC may develop. Responsible for Provider contract compliance. Coordinates with
Network Management, Claims and Health Services to ensure adequate set up and comprehensive interpretation of
new contract fees and requirements. Assists with provider profiling, working closely with Finance, Provider Relations,
Member Services, Health Analysis and Health Services to provide reports, assist with analysis and recommend actions.
Reviews quantitative analysis of various types of data including provider contracts, fee schedules, utilization and claims
data needed for assessing, planning, budgeting, cost control and contract administration and makes recommendations
for contracting rates and policies.
Education/Specialized Training/Licensure: Bachelor's degree in Marketing, business or related field; may substitute
experience for education.
Work Experience (Years and Area): Five plus ( 5+) years in a health plan, with at least three (3) years experience Providers /
Managed Care, Contracting and Relations.
Equipment Operated: PC and own transportation
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing /Composing (Correspondence / Reports )
2. Other Skills:
Analytical Medical Terms Statistical P.C. MS Word MS Excel
3. Advanced Education:
4. Work Schedule: Flexible
5. Other Requirements:
Must have car and valid Texas Drivers license. Must have managed contract negotiation
experience, preferably in Houston market.