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Role Title: Provider Relations Specialist

Reports To: Director of Clinical & Quality Operations

Last Updated: February 23, 2022

Position Summary

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.

Qualifications

  • 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

Position Tasks

  • 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 contact@cbhallc.com

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