Network Relations Consultant

CareMore Health•Los Angeles, CA

7d•Onsite

About The Position

The Network Relations Consultant is responsible for assigned network PCP performance including PAHAF completion, AWV and Star rating of 4 or above. The Network Management Consultant will own individual performance engagement and on-the-ground relationship development for new and existing MDs. This role develops and maintains positive provider relationships with the provider community by regular on-site visits, communicating administrative and programmatic changes, and facilitating education and the resolution of provider issues. Serving as a knowledge and resource expert regarding provider issues impacting provider satisfaction, this role researches and resolves complex provider issues and appeals for prompt resolution. May be responsible for coordinating non-negotiated contracts for new and existing providers as needed. Researches, analyzes and recommends resolution for contract disputes, non-routine claim issues, billing questions and other practices. May participate in Joint Operation Committees (JOC) of larger provider groups. Coordinates communication process on such issues as administrative and medical policy, reimbursement and provider utilization patterns. Conducts seminars to support the understanding of managed care policies and procedures. Identifies network access and deficiencies and develops recruitment and contracting strategies. Coordinates and conducts provider training including developing and distributing provider relations materials. Responsible for providing quality, accessible and comprehensive service to the company's provider community. Provides assistance regarding education, contract questions and non-routine claim issues. Coordinates prompt claims resolution through direct contact with providers, claims, pricing and medical management departments. Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery. Tracks and conducts provider refresher training. Researches issues that may impact future provider negotiations or jeopardize network retention.

Requirements

Requires a Bachelor's degree
Minimum of 3 years of customer service experience
Minimum of 2 years experience as a Network Management Rep
Any combination of education and experience which would provide an equivalent background
Travels to worksite and other locations as necessary
Focus on Quality and AWV: Consistent PCP visits focused on PAHAF completion, STARS gaps closed, HCC Re-capture rate, PCP referrals
Focus on Provider Education
Focus on Model of Care
Focus on Portal usage/training
Focus on Referrals and authorizations
Focus on New PCP on-boarding
Focus on Issue Resolution: Claims, Referrals and authorizations, G&A

Responsibilities

Own individual performance engagement and on-the-ground relationship development for new and existing MDs.
Develop and maintain positive provider relationships through regular on-site visits.
Communicate administrative and programmatic changes to providers.
Facilitate education and resolve provider issues.
Serve as a knowledge and resource expert regarding provider issues impacting provider satisfaction.
Research and resolve complex provider issues and appeals for prompt resolution.
Coordinate non-negotiated contracts for new and existing providers as needed.
Research, analyze, and recommend resolutions for contract disputes, non-routine claim issues, billing questions, and other practices.
Participate in Joint Operation Committees (JOC) of larger provider groups.
Coordinate communication processes on issues such as administrative and medical policy, reimbursement, and provider utilization patterns.
Conduct seminars to support the understanding of managed care policies and procedures.
Identify network access and deficiencies and develop recruitment and contracting strategies.
Coordinate and conduct provider training, including developing and distributing provider relations materials.
Provide quality, accessible, and comprehensive service to the company's provider community.
Provide assistance regarding education, contract questions, and non-routine claim issues.
Coordinate prompt claims resolution through direct contact with providers, claims, pricing, and medical management departments.
Identify and report on provider utilization patterns that impact the quality of service delivery.
Track and conduct provider refresher training.
Research issues that may impact future provider negotiations or jeopardize network retention.
Ensure assigned network PCP performance including PAHAF completion, AWV, and Star rating of 4 or above.