Provider Network Field Representative
This position develops, contracts, maintains, and enhances relationships with facilities, physicians and ancillary providers within designated geographic area(s) to drive business results. This position is responsible for the appropriate representation of providers relating to contractual arrangements, compliance, regulatory, credentialing, claims, provider files and administrative policy and procedures. This position may be assigned to service sponsors and/or other large provider entities, possibly in multiple boroughs.
Essential functions are job duties and responsibilities that must be performed to accomplish the purpose/ goals of the job.
• Successfully execute all processes to support the Provider Directory and other pertinent reports. This includes, but is not limited to, modifications of records to assure appropriate support of business processes and all other activities in a timely manner.
• Ensure provider data is entered in systems in alignment with contractual agreement.
• Partners with other internal departments, including but not limited to Health Services, Finance, Claims, and Coding in order to develop solutions for strategic business needs.
• Conducts limited negotiations and drafts contract amendments.
• Conduct regular service visits to ensure provider service needs are met, resolve issues, educate providers and provider staff on policies and the web-portal usage, collect credentialing information, and review Healthcare Effectiveness Data and Information Set (HEDIS) information, etc.
• Work closely with key Departments to ensure successful implementation of Provider Agreements from initiation to approval, including provider credentialing applications, environmental site reviews, system configuration, and orientation.
• Ability to have intimate knowledge of how provider practices operate and how plan policies may impact or be impacted by this structure and understanding of various reimbursement methodologies and how it relates to cost
• Serve as plan liaison for physicians/physician groups in a specified geographical area. Will be main point of contact for all plan-related issues including contracting, billing and reimbursement. Responsibility for the resolution of all issues, including those identified by the provider, and those identified internally that have an impact on the physician.
• Implement and/or provide ongoing relationship management for large, high profile physician groups, Independent Practice Associations (IPAs), and hospital systems with positive business results.
• May participate in intradepartmental projects or smaller projects impacting multiple departments
• Maintain accurate, up-to-date information regarding key contact, clinical, and other key staff at Provider practices and hospitals
• Provide delegated provider with quarterly roster participating providers and oversee audits for accuracy.
• Manage delegated roster submission and assure timely receipt and loading into provider database.
• Operates with general supervision, elevating unusual situations to management as required.
MINIMUM JOB REQUIREMENTS
• Bachelor’s Degree in health care administration, business or an equivalent combination of education and work experience in managed care or health care.
• Minimum of five years’ experience in health care; including a minimum of three years in provider/ payor contracting.
• Extensive experience in developing contract types, fee arrangements and other contract terms and in developing and recommending potential solutions to contract issues.
• Proficiency in Microsoft Office software (Word, Access, Excel).
• Ability to travel efficiently and continuously to and within assigned geographic area.
• Strong organizational and project management skills.
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization’s vision, mission, and values.