Position Summary
Acts as the primary resource for assigned, providers or groups (i.e. local, individual providers, small groups/systems) to establish, oversee, and maintain positive relationships by assisting with or responding to complex issues regarding policies and procedures, plan design, contract language, service, claims or compensation issues, and provider education needs.
Optimizes interactions with assigned providers and internal business partners to establish and maintain productive, professional relationships.
Monitors service capabilities and collaborate cross-functionally to ensure that the needs of constituents are met and that escalated issues related but not limited to, claims payment, contract interpretation or parameters, and accuracy of provider contract or demographic information are resolved.
Supports or assists with operational activities that may include, but are not limited to, database management, and contract coordination. Performs credentialing support activities as needed.
Educates providers as needed to ensure compliance with contract policies and parameters, plan design, compensation process, technology, policies, and procedures.
Meets with key providers periodically ensure service levels are meeting expectations. Manages the development of agenda, validates materials, and facilitates external provider meetings.
May collaborate cross-functionally on the implementation of large provider systems, to manage cost drivers and execute specific cost initiatives to support business objectives and to identify trends and enlist assistance in problem resolution.
Conduct standard provider recruitment, contracting, or re-contracting activities and assist with more complex contracting and discussions as needed by business segment.
May provide guidance and training to less experienced team members.
Required Qualifications
3+ years' experience in business segment environment servicing providers with exposure to benefits and/or contract interpretation.
Working knowledge of business segment specific codes, products, and terminology.
3-5 years experience with business segment specific policy, benefits, plan design and language.
Strong verbal and written communication, interpersonal, problem resolution and critical thinking skills.
Preferred Qualifications
5 + years' experience with business segment specific policy, benefits, plan design and language.
Education
Bachelor’s Degree or equivalent combination of education and experience.
