Provider Network Representative

This position develops and maintains relationships with primary care and specialty physicians and ancillary providers for all product lines 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.

ESSENTIAL FUNCTIONS
Essential functions are job duties and responsibilities that must be performed to accomplish the purpose/ goals of the job.

• Develop and retain effective relationships with primary care and specialty physicians and ancillary providers for all product lines within designated geographic area(s) to drive business results.

• 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.

• Respond to incoming provider inquiries and resolve issues.

• Coordinate exchange, data updates, and follow-up of credentialing delegation rosters, provider file related functions, and provider rates implementation initiatives.

• Identify potential claims trends, identify systems trends, and correct root causes for organization’s provider systems data issues.

• Conduct monthly calls to provider network to ensure compliance with IPRO/ Access and Availability.

• Monitor contracts to ensure contract administration objectives are achieved and oversee provider data quality assurance.

• 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.

• Contract with community and hospital based physicians and ancillary providers.

MINIMUM 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 three years’ experience in health care; including a minimum of two years in provider/ payer contracting.

• 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, including possessing a reliable personal vehicle.

• Excellent 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.

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