Spec Provider Relations & Contracting
HealthNow New York Inc. - Buffalo, NY

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Position Summary: The Provider Relations and Contracting Account Specialist is the primary contact for the development of relationships between HealthNow and provider groups/facilities and organizations for a defined territory. Provides recruitment, quality service, and education to provider groups to maintain adequate provider network, meeting with appropriate personnel to maintain a successful relationship resulting in substantial strategic advantage to the organization.

Primary Job Duties:
  • Primary responsibility is developing, improving, and maintaining contractual relationships with provider organizations within their territory as well as receiving and responding to telephonic, email & fax inquiries. Responsible to complete in-office visits with providers and manage all encounters with providers and internal customers through the timely completion of inquiries. Coordinates negotiations and contracting for all contract types including standard, unique and quality based. Manages the day to day relationship between these groups, IPAs and HealthNow. Acts as a liaison between provider offices and HealthNow for operational issues, making independent decisions based on company goals Ensures Director and Manager and Chief Medical Officer awareness of provider organization activities and facilitates appropriate participation in them. (20%)
  • Oversees and analyzes contract performance including trends, practice patterns, cost utilization and access and educates providers to ensure cost appropriate care in support of Health Care Services initiatives focused on managing medical expense and maximizing HEDIS, STAR and QARR metrics such as Pay for Performance Program Team, the Provider Engagement Strategy Team, and supporting the STAR Initiatives. Involves other members (i.e. clinical staff) to assist in education process. Reports and makes recommendations to next level of management regarding findings. Participates in continuous quality improvement activities with other members of Provider Relations that will contribute to improving the Department's processes. Participation in the validation process for each Pay for Performance settlement. (20%)
  • Advises and supports the Management Team, initiating and managing research and development activities relating to provider educational goals. (5%)
  • Works with various departments/teams in the Company to communicate medical, reimbursement, and operational policies and procedures to provider. Ensures that our policy directives and the provider's contractual obligations are enforced while maintaining the credibility and respect of providers. (10%)
  • Maintains tracking of monthly encounters, monthly reports, recruitment plans, and weekly itinerary plans. (5%)
  • Actively Participates in assigned work teams, committees, projects, etc. representing Provider Relations/Contracting role in regards to business and operational systems.. Acts as Project Manager for Provider Relations and Contracting projects, such as NCQA, HPN, Pay for Performance and DOH Reviews. (10%)
  • Coordinate to develop and present annual provider Expo's as well as multiple focus groups/seminars. (5%)
  • Performs all aspects necessary to begin the contracting and credentialing/enrollment process for new providers and new locations including, but not limited to: Onsite reviews, Access Compliance reviews, After Hour access review, assistance with demographic change forms & new provider forms, government list reviews, routing slip preparation, Notice of Coverage Change, and all associated reporting. Also performs research related to provider terminations including access to care. (10%)
  • Manage and escalate claims review to resolution of root problem to include coordination between departments for various products and any follow up required with those departments. Also performs timely filing request review. Responds to service inquiries and all research and follow up necessary to resolve. (5%)
  • Coordinate responses to government and regulatory agency audits, including, but not limited to: quarterly Health Provider Network (HPN) NYS DOH, Semi-annual Medicaid Managed Care telephone & IPRO audits as necessary, develop and implement corrective action plans. (varies per region). (10%)
  • Performs other related duties as required.
Required Skills Primary Skills/Knowledge:
  • Excellent time management skills
  • Project management skills
  • Public presentation skills
  • Excellent organizational skills and attention to detail
  • Excellent verbal and written communication skills
  • Strategic thinking/planning skills
  • Ability to work effectively with minor supervision
  • Must be able to work in a fast-paced environment with daily work processing deadlines
  • Prior experience in a fast-paced face-to-face customer service role working with daily deadlines and interruptions required
  • High degree of business maturity and demonstrated confidentiality
  • High energy level and ability to project enthusiasm
  • Persuasive communication style
  • Polished, professional image and reputation
  • Demonstrated customer service orientation
  • Demonstrated personal accountability
  • Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
  • Excellent problem solving skills
  • MS Word, MS Excel, MS PowerPoint, MS Access and Visio - Intermediate
Required Experience Preferred Education: Associates Degree (N/A)

Preferred Experience: Or 2-3 years work experience in a similar function required.

Alternate Education: No degree specified (N/A)

Alternate Experience: 5 years work experience in Health insurance claims or customer service. Provider relations and/or contracting experience and Health care professional preferred.

Alternate Education: Associates Degree (N/A)

Alternate Experience: 2-3 years work experience in Health insurance claims or customer service. Provider relations and/or contracting experience and Health care professional preferred.

Working Conditions:
  • Must be able to accommodate local travel. Valid drivers license and acceptable driving history required due to travel involved with this position (DMV check will be conducted to review candidate's driving record)
  • Must be able to work in an office environment
  • Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively use a computer with all its components for prolonged periods of time and for the majority of required tasks
  • Manual Dexterity Req: Eye-hand coordination and manual dexterity sufficient to effectively utilize various office equipment (phone, computer, fax machine, printer, copier, filing cabinet, etc)
Required Licenses/Certifications:
  • Driver's License/DMV Check Required

HealthNow New York Inc. - 19 months ago - save job - block