Senior Provider Network Representative
This position develops, contracts, maintains, and enhances relationships with key high volume facilities and physicians 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.
• Develop and retain effective relationships with physician and business leadership of key physician groups and delivery systems within designated geographic area(s) to drive business results.
• Act as resource for others with less experience.
• Responsible for more complex and high priority contracted health systems.
• 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 from assigned providers and resolve issues. Assist colleagues with complex provider inquiries.
• Implement and/or provide ongoing relationship management for large, high profile physician groups, Independent; Practice Associations (IPAs), and hospital systems with positive business results.
• Coordinate exchange, data updates, and follow-up of credentialing delegation rosters, provider file related functions, and provider rates implementation initiatives.
• 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.
• 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