Regular
Exempt
GENERAL DESCRIPTION:
Responsible for identifying, analyzing, and implementing cost management opportunities through provider strategic initiatives, evaluation of utilization patterns, and value-based care models. Ensures that strategy plans are translated into actionable initiatives, operationalizing them across the healthcare network. Collaborates cross-functionally with analytics, finance, clinical, and provider relations teams to ensure alignment with organizational goals and regulatory requirements.
ESSENTIAL FUNCTIONS:
Supports the evaluation and implementation of network initiatives, including market assessments and disruption analyses, to ensure regulatory-compliant network adequacy and access standards.
Develops, delivers, and promotes educational content for internal teams and external stakeholders, serving as a liaison between providers and operational units to resolve service, credentialing, and contracting issues efficiently.
Supports the Contracting & Credentialing Operations Unit provider requests across Puerto Rico for contract onboarding, amendments, and renewals, managing documentation, process standardization, and adherence to company policies, aligned with the Network Management Strategic Plan.
Designs and prepares reports and presentations that communicate departmental objectives and network initiatives, aligning stakeholders across operational and compliance functions. Supports the creation and maintenance of regulatory documentation in line with federal, state, and organizational requirements.
Collects and synthesizes analytical reports to document and present proposed initiatives effectively to management.
Collaborates with provider contracting teams to design and negotiate agreements that incentivize quality outcomes, improve cost efficiency, and support value-based care transformation.
Contributes to the implementation of alternative payment models, including value-based agreements and bundled payment options, facilitating improved care delivery.
Maintains accurate provider data and demographic records, ensuring updates are communicated to support effective network operations and member access.
Support providers by identifying and removing barriers, addressing issues or concerns promptly to enhance provider satisfaction.
Assist in planning and executing provider network events and special initiatives aimed at strengthening provider relationships and engagement.
Conducts on-site provider audits and evaluations, monitoring compliance with contract terms, quality standards, and healthcare regulations to ensure operational and regulatory compliance.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor's Degree in Health Administration, Business Administration, or related fields. At least three (3) years of experience in health insurance, network strategy, or medical cost analytics, preferably in the Healthcare Industry.
"Proven experience may be replaced by previously established requirements."
Certifications / Licenses: A valid driver's license in the Commonwealth of Puerto Rico is required.
Other: Car in good condition and available to travel to different locations in Puerto Rico. Knowledge of provider contracting, claims data, and healthcare economics.
Languages:
Spanish – Intermediate (comprehensive, writing and verbal)
English – Intermediate (comprehensive, writing and verbal)
"MCS Healthcare Holdings, LLC. (MCS) is an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities. MCS is a participating E-Verify employer.