Acts as the primary operational contact between BMCHP (“Plan”) and key provider organizations, taking the lead and promoting collaboration within Plan, as it relates to provider network maintenance. Manages territory inclusive of one or more of highest priority network partnerships, as well as multiple other providers, facilities and community health centers. Works closely with the Regional Provider Relations Manager to identify issues and report trends. Acts as liaison between provider and internal Plan departments such as Claims, Audit, Marketing, Member and Provider Enrollment and Health Services.
- Monitors provider access and availability, recruiting key providers when and where appropriate. Manages recruitment process related to expansion efforts, assures adequate member access and supports provider referral patterns. Coordinates and distributes provider contracts and related materials.
- Works collaboratively with Provider Relations Consultants and Regional Manager to maintain and update provider orientation programs and recruitment initiatives.
- Coaches and assists in the training of Provider Relations Consultants and Provider Relations Specialists.
- Organizes, prepares and conducts orientations of key network providers and their staff. Takes the lead on specific Plan initiatives as they relate to provider education. Provides general instruction and support on BMCHP products and policies to providers and coordinates office and provider administrative meetings.
- Meets with assigned providers regularly according to pre-set site visit servicing standards. Documents all pertinent provider communications and meetings in Onyx.
- Acts as liaison for all reimbursement, credentialing, claims, EDI web site procedures and issues of key providers. Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary .
- Provides general education and support on BMCHP products, policies, procedures and operational issues.
- Works collaboratively with Contract Managers in implementing and administering contractual provisions of provider agreement to ensure contractual compliance. Monitors contractual compliance on an on-going basis.
- Manages the implementation of new provider contracts, assisting when needed, so providers can be credentialed, loaded in systems and notified within standards set by department.
- Manages flow of information to and from provider offices. Monitors and communicates market trends and issues.
- Outreaches to providers according to Plan initiatives.
- Analyzes operational issues with regard to territory and provider operations such that interrelationships among other area providers are considered.
- Facilitates problem resolution. Initiates Plan interdepartmental collaboration to resolve complex provider issues.
- Identifies system updates needed and completes research related to provider data in Onyx and Facets.
- Processes reports as needed to support provider education, servicing, credentialing and recruitment.
- Assists in developing marketing materials. Participates in community outreach activities and events.
- Ensures quality and compliance with MassHealth, The Connector and NCQA.
- Other responsibilities as assigned.
- Regular and reliable attendance is an essential function of the position.
- May provide technical supervision to less experienced staff as needed.
- Bachelor’s degree in Business Administration, related field, or an equivalent combination of education, training and experience is required.
Competencies, Skills, and Attributes :
- 4 or more years progressively responsible experience in provider relations or network management required.
Working Conditions and Physical Effort:
- Demonstrated competence using Microsoft Office products especially Word, Excel, Outlook, Access, PowerPoint. Experience or knowledge of FACETS.
- Effective communication skills (verbal and written).
- Ability to work as a team member. Must be able to manage multiple tasks and possess excellent organizational skills. Ability to be flexible and work independently.
- Must be willing to travel significantly to local communities to meet business needs up to 75% of time.
Boston Medical Center HealthNet Plan - 2 years ago