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This role will be responsible for the development and maintenance of collaborative relationships with providers (physician, hospital, ancillary, vendors etc.) based on mutual respect, high-quality outcomes, and patient and provider satisfaction. The role works to continually shape the network landscape, by offering objective data and education to all stakeholders in the market and all product lines. The incumbent will report to the Manager Network Services and will be an integral and collaborative member of the Provider Relations team.
The incumbent will be detail oriented and an excellent communicator who is ready to take on a new, challenging career in the market!

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in business, or healthcare related field

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s Degree in Healthcare Administration or Business Administration

2. Certified Medical Coder (CMC) through the American Academy of Professional Coders (AAPC) 

EXPERIENCE:

1. Basic understanding of Contracts, Value Based Reimbursement (VBR) and/or performance-based provider reimbursement programs, and Commercial (fully insured and self-funded), Medicare Advantage, Medicaid, PEIA products.

2. Understanding of Regulatory Reporting for provider networks, e.g., WV Department of Insurance, Department of Medicaid/Health Services and CMS.

3. Understanding of provider quality measurements and systems such as Medicare STARS, HEDIS, and PCMH quality programs.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

 

1. Upholds the health plan mission of making make healthcare more accessible, understandable, and collaborative while interacting with providers and colleagues.

2. Educates providers regarding policies and procedures related to credentialing, contracting, authorizations, referrals, claims and/or encounters, grievances and appeals, health education, provider education, population health management, care management, pharmacy management, Electronic Health Records and medical record submissions, Health Information Exchange, data exchange and electronic Data Interface and regulatory updates.

3. Builds and maintains strong provider relationships.

4. Conducts routine periodic outreach to providers based upon business plan and operational goals to include e-mail, telephone, in-person, and scheduled webinar meetings.

5. Ongoing assessment of provider efficiencies when dealing with health plan.

6. Conducts initial provider orientations as well as ongoing educational outreach.

7. Conducts group training sessions.

8. Assists with simple provider contract questions including researching problems and resolving escalated issues.

9. Represents health plan at healthcare association functions i.e.  HFMA, MGMA, AMA

10. Participates in regulatory reporting for provider networks, e.g., WV Department of Insurance, Department of Medicaid/ Health Services and CMS.

11. Keep abreast of competitors and regulation in market.

12. Supports strategic positioning in geographic areas to develop and maintain provider networks.

13. Assist Credentialing Department with any difficult to obtain documents.

14. Initiates and maintains effective channels of communication with matrix partners including but not limited to, Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing and Member and Provider Service, to resolve issues and facilitate team and business priorities/opportunities.

 

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

 

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

1 Standard office environment 

2. Some travel may be required to offsite meetings

 

SKILLS AND ABILITIES:

1. Strategic thinking and attention to detail

2. Knowledge of federal and state laws, such as CMS, BMS, etc.

3. Excellent written and oral communication

4. Demonstrated ability to build and retain relationships

5. Proficiency with Microsoft Office

6. Experience with Commercial (self-funded and fully funded), Medicare and Medicaid products.

7. Understanding of the provider credentialing and data management process.

8. Working knowledge of claims, and/or coding.

9. Established provider relationships in West Virginia

Additional Job Description:

Other duties asassigned

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2901 PHH Provider Management