Serves as primary liaison between network participating providers and the Plan. Scope of responsibility includes, but is not limited to: regular visitation to participating provider office(s); initiating new provider agreement contacts and associations; conducting educational sessions (accomplished through in-service, workshops, and one-on-one meetings); claims issue coordination; development of materials to assist providers; provider contracts and file maintenance; and network listing maintenance.
Primary Duties & Responsibilities:
Required Competencies and Qualifications:
- Communicate with providers via phone, email, letters, fax and personal visits in a positive and customer focused manner resulting in improved perception and satisfaction
- Identify opportunities for process improvements that impact providers
- Propose process improvements that enhance provider and customer satisfaction
- Promote AlohaCare
- Initiate conversations that sell AlohaCare to providers, customers, and the community
- Demonstrate superior knowledge regarding claims, referral/auth/notification process, formulary, benefits, contracts, fees and other provider issues
- Respond to provider inquiries, complaints, etc. immediately
- Assess the provider network to develop recruitment strategies
- Assess the need to do a facility site review based on our observations during provider visit
- Assess provider operational procedure to identify training needs
- Assess provider complaints or questions and determine the course of action to bring them to resolution
- Participate in provider events
- Give input and feedback at weekly department meetings, public relations meetings and workgroups
- Participate in corporate priority project teams like EQRO, URAC accreditation, etc.
- Investigate provider claim issues and develop an appropriate resolution
- Research provider profiles including claim, complaints, grievances, and appeals history
- Analyze organizational impact of fee increases, contract changes, etc
- Identify AlohaCare business needs in relation to contracting with new providers
- Review provider contract conditions, agreements, stipulations, requirements, etc.
- Identify and analyze provider trends including demographic availability, perception and satisfaction levels, unique profiles, etc
- Update and maintain a current and accurate provider directory
- Streamline workflows
- Expeditiously analyze claim and reimbursement issues
- Propose resolution to provider inquiries, complaints, etc.
- Solicit feedback from key players
- Analyze business needs for providers and recruit targeted providers
- Immediately alert team of provider dissatisfaction, identify issues that affect provider retention and identify “at-risk” providers
- Develop strategies to retain providers while enhancing their perception and satisfaction
- Organize and conduct provider trainings to enhance provider perception and satisfaction and reduce provider grievances.
- Present interdepartmental trainings for provider related processes and solicit input to ensure appropriateness of training & provider education materials
- Assist in developing all provider communications including the provider manual, provider quick notes, website, newsletters, provider bulletins, provider fax blasts, etc.
- Assist in developing provider training materials
- Alert team of any provider issues that impact AlohaCare
- Survey providers
- Complete provider visit summaries
- Communicate in a customer-focused manner either via telephone, print, or in person
- High School Diploma
- Significant managerial & leadership skills & experience in building provider relations
- Ability to make decisions
- Excellent customer service skills
- Ability to give input in improving product or processes and work independently
- Outcome focused and deadline driven, accurate, committed to excellence.
- Demonstrates corporate core values.
- Knowledge of basic office equipment/computer systems
- current valid Hawaii driver’s license along with access to an insured vehicle is required.
Required Licensure / Certification:
Preferred Competencies and Qualifications:
- Conflict Resolution training or certification
- Account Management training or certification
- Bachelor’s Degree with relevant coursework in business management, communications,
sales, and contracts
- Experience working with Medicare/Medicaid
- Knowledge and working experience with Long Term Care Plans
- Understanding of claims analysis and managed health care, Medicare, provider
contracting, providers’ billing practices and selling experience is highly desirable.
AlohaCare - 15 months ago