The Provider Relations Representative I is responsible for assistance to and support of the Provider Relations staff. Additionally, this position is the back-up for internal/external issues concerning Provider Relations, when the Provider Relations Representative II’s are unavailable, including provider education and support and resolution of provider issues.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Update monthly membership list to ensure that each PCP has current membership roster in a timely fashion (monthly recurring process).
Identify out-of-network providers for services not available in network.
Complete preparation and negotiation of LOAs for out-of-network providers for services not available in network or for continuity of care; fax fully executed LOAs to providers.
Coordinate communication to Plan’s other departments to ensure access to care and contract configuration for LOAs for out-of-network arrangements.
Review contracts for submission, complete credentialing check list assuring that all supporting documents are attached and current; keep log of those submitted.
Coordinate New Office Orientations process for re-credentialing cycle.
Utilizing service guidelines, maintain network stability as it relates to physician/provider terminations and panel closing by primary care physicians.
Work closely with other departments in the maintenance of Provider Directory.
Manage provider demographic information changes (tax identification numbers, new addresses etc.) and resolve identified problems.
Negotiate contracts with specialists to support network adequacy and enhance network.
Provide education and support to providers.
Resolve provider issues, including claims research, root cause analysis and resolution of system load issues or provider billing errors. Re-contract as necessary.
Coordinate with other departments to resolve provider issues.
Abide by all compliance requirements for the Department of Insurance (DOI), Agency for Health Care Administration (AHCA) and the Centers for Medicare and Medicaid Services (CMS) as these apply to the Provider Relations Department activities.
QUALIFICATIONS AND REQUIREMENTS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
EDUCATION and/or EXPERIENCE: An undergraduate degree from an accredited institution of higher learning required; minimum of one year of experience in the managed care industry with a focus on contracting preferred; or an equivalent combination of education, training and experience.
NECESSARY KNOWLEDGE, SKILLS AND ABILITIES: Ability to navigate and master proprietary software programs. Ability to read and interpret documents, excellent communication skills, good grammar, voice and diction, proficient in MS Office, basic computer and keyboarding skills. Ability to formulate and articulate persuasive dialogue and to understand and convey complex financial information to providers.
LICENSING AND CERTIFICATION: None required for this position.
REQUIRED TRAVEL: Availability for occasional ground and air travel may be required.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit. The employee frequently is required to use hands 10 finger, handle, or feel objects, tools, or controls and talk or hear.
Specific vision abilities required to this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
WORK ENVIRONMENT : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
The noise level in the work environment is usually moderate.
For the most part ambient room temperatures, lighting and traditional office equipment as found in a typical office environment.
ADDITIONAL INFORMATION: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position.
We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.
Freedom Health - 18 months ago