Role Title: Provider Relations Specialist
Reports To: Director of Clinical & Quality Operations
Last Updated: February 23, 2022
The Provider Relations Specialist is an outward-facing organizational representative with expertise in health care network operations including network management, provider relations, contracting, and performance analysis; Coordinates all activities related to provider network including recruitment, credentialing, rate negotiation, contracting, complaint investigation and resolution; Strives to meet and maintain network compliance with accessibility and availability standards; Works collaboratively with administrative and operational areas within CBHA to ensure the accuracy, timeliness, and usability of CBHA’s provider network database.
- Bachelors’ degree (preferred)
- Minimum 3 years’ experience in network management including provider credentialing and contracting
- High degree of knowledge and working experience in medical terminology, provider billing practices, patient referrals, eligibility information, contracting, claims processing, and adjudication required.
- Functional knowledge of NCQA standards specific to provider network management
- Working knowledge of all applicable state and federal regulations
- Exceptional verbal and written communication skills
Position Duties & Responsibilities * Builds relationships with key providers and is primary point of contact for day-to-day and overall provider relations and service interactions
- Monitors, analyzes and reports trending provider issues to the Director of Clinical and Quality Operations and assists in closing care gaps and improving access to care.
- At the direction of the Director of Clinical and Quality Operations, manages contract development, negotiation of terms and metrics, and performance
- Responsible for and monitors all content on provider tab of CBHA website.
- Leads resolution of escalated issues related but not limited to claims payment and contracting
- Actively participates in the continuous quality improvement program of the organization
- Makes operational change suggestions to improve the delivery of services
- Monitors and tracks provider complaints and makes recommendations for improvements, including policy changes
- Identifies and tracks provider accessibility and availability for a full complement of behavioral health providers (facilities, facility-based programming, group practice and individual practice). Pursues contracts at the direction of the Director of Clinical and Quality Operations.
- Provides feedback on geographic distribution of providers concerning availability and appropriate mix of behavioral health providers/facilities to serve enrollees.
- Maintains and monitors a tracking system to assure provider contracts are current and compliant with DOI requirements
- Negotiates, maintains and tracks negotiated facility rate increases and communicates these to the Claims Department in a timely manner
- Produces quarterly Provider Newsletters for distribution
- Monthly, quarterly, annual network status reports
- Weekly, monthly, quarterly, semi-annual, annual network related reporting
- Provider Satisfaction Survey
- Provider Accessibility Survey
- Termed Provider report & member notification
- Provider profiling
- Enrollee dissatisfaction with providers trends
- Works with Administrative Assistant of Provider Relations to assure that CBHA’s internal credentialing/recredentialing process with regard to primary source verification and assures process is completed within the prescribed time frames
- Works with Administrative Assistant of Provider Relations to assure the preparation and storing of provider communication with regard to credentialing/recredentialing, W-9 discrepancies, etc.
- Develop and update all recruitment correspondence and packets
- Facilitates quarterly BQIC meeting
- Provides input for credentialing and professional relations policies & procedures
- Audits delegated credentialing files, per standards
- Handles escalated provider calls and communications
- Backs up Administrative Assistant of Provider Relations
Job Type: Full-time
Pay: $19.00 – $24.00 per hour
If you would like to apply for the position send your resume to firstname.lastname@example.org