Provider Relations Specialist - RCM Healthcare Services : Job Details

Provider Relations SpecialistLocation: Manhattan, NYSalary: $70,000 - $75,000Hybrid Role - Three Days a week working in Midtown, Manhattan Office and Two Days a week working remotely. Musthave 3+ years of experience working with a health plan in provider relations, provider contracting, provider network development or provider credentialing.Summary:Serves as the liaison between the Plan and our network of healthcare providers. Develops and maintains relationships with the provider network community. Responsible for educating the network on Plan standards and TRICARE requirements. Responsible for new provider orientation program and ongoing training to ensure understanding of Plan policies, programs, TRICARE requirements and contractual obligations. Monitors network adequacy and responds appropriately; collaborates with marketing/sales and family practice center staff to ensure beneficiaries needs are fulfilled. Serves as the primary point of contact to address inquiries and resolve issues; track, trend and report provider inquiries/issues to management.Responsibilities:

• Actively communicate with prospective and contracted providers based on business needs.
• Guide prospective providers through application, credentialing, and contract process (provider onboarding).
• Conduct prospective provider in person site visits, as applicable to Plan requirements.
• Conducts new provider orientation and on-going provider trainings, as required.
• Foster and promote positive provider network relationships.
• Develop and strengthen relationships with providers/office staff and key stakeholders.
• Maintain an accurate list of contacts, including but not limited to, Managed Care, Credentialing, Claims, Contracting, Quality and Population Health executives and/or representatives.
• Manages territory, inclusive of strategic network partnerships and the Plan's family health centers and marketing staff.
• Serve as the primary point of contact, providing general instruction and support on all products, provider manual inquiries, accuracy of the provider directory, ensuring data integrity, adherence to Plan policies and Plan procedures; claims management.
• Schedule and conduct provider office/facility visits to all high-volume providers in accordance with department project plan and initiatives.
• Investigate, resolve, and respond to provider inquiries including, but not limited to participation requirements, credentialing requirements, credentialing status, contract terms, fee schedules, claims management, reimbursement, utilization, access/availability standards, member eligibility, consult report requirements, provider payment configuration.
• Document and track inquiries received and monitor towards resolution in accordance with Plan policy and TRICARE regulations.
• Facilitate interdepartmental collaboration to resolve complex provider issues; track and trend issues.
• Partner with marketing/sales teams and participate in outreach activities/events, targeting market growth, penetration and building brand recognition.
• Prepare analytical reports of network status including gaps/access and availability
• Monitor contract performance and network adequacy through site visits, claims and data analytics.
• Enforce quality and regulatory compliance guidelines; participate in HEDIS activities.
• Collaborate with Quality Department (HEDIS) to help reinforce Plan quality standards and increase positive patient outcomes.
• Additional inter/departmental duties as assigned.

Experience:

• 3-5 years' experience in health insurance, provider relations, provider contracting, provider network development or provider credentialing.
• Or in lieu of the above, a minimum of 5-8 years relevant work experience with an Associate's degree or Bachelor's in progress.
• Access to personal vehicle
• Valid driver's license
• Able to lift 20 pounds

Education/Certifications/License

• Associate's Degree Required or Bachelor's Degree Preferred
• Valid driver's license.
• Must be able to work HYBRID. 3x a week in office.

INDP#AC1#ACP