Job Description

Job description

This position is responsible for assisting in the communication and dissemination of information to the current community of Affiliate MSO Medicare Advantage providers. This position will be assigned provider accounts to guide, manage, and communicate directly with the Physician Staff and Providers assisting with technical support on topics including but not limited to service, network, MRA & HEDIS compliance Utilization, Claims and Credentialing.

ESSENTIAL FUNCTIONS:

• Owns and manages contractual relationship and performance of assigned in-network Affiliate provider groups.
• Serves as primary point of contact for assigned providers.
• Evaluates provider performance via Affiliate Provider Dashboard and develops performance action plans.
• Completes new provider orientation for all applicable product lines to educate on policies and initiatives, resolve issues, and educate staff/providers.
• Drives adoption, discussions and utilization of Provider Payor Portals, Medcloud, AaNeelCare, Accureports (Rx, Hospital and ER Discharge, Medical Expenses via PMPM views)
• Establishes consistent and strong relationships with provider groups utilizing an account management approach
• Establishes and leads cross-functional communication with internal departments. (MRA & HEDIS departments)
• Collaborates with internal cross-functional team to support provider performance and resolve barriers and challenges on a monthly basis.
• Drives improvement of provider performance by educating, analyzing, interpreting, communicating utilization and quality metrics. Responsible for developing and executing performance improvement plans.
• Has understanding and explains full risk contract reimbursement to providers and management leads cross-functional communication and works with internal support team to resolve provider contractual inquiries.
• Plans, prepares, and executes effective group monthly meetings/discussion with proper objectives and expected outcomes with cross-functional communication on internal and external customers.
• Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.
• Provides continual training to assigned providers on provider portal and other resources to assist with claims, authorizations, member support, etc.
• Provides oversight of delegated functions, as applicable.
• Performs special projects/campaigns as assigned.

ADDITIONAL RESPONSIBILITIES:

• Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy, working with internal support team

CANDIDATE EDUCATION:

• Required A Bachelor's Degree in a related field
• Required or equivalent work experience

CANDIDATE EXPERIENCE:

• Required 1 year of experience in a Provider Relations, Account Management, Customer Service, or relevant position with demonstrated ability to perform the duties of the position
• Preferred Other Experience working in healthcare; with an IPA/MSO/HMO/PPO environment
• Strong skill set/versed in HEDIS & MRA compliance
• English/Spanish Preferred; other language requirements may vary by location

Job Type: Full-time