Provider Engagement Representative

Health One Alliance•Dalton, GA

10h•Onsite

About The Position

The Provider Engagement Representative is responsible for servicing providers through public relations, problem solving, education, communication and support of Company policies and procedures. This role will provide education, training, and support for all providers. This position will also work to establish and maintain Medicaid CMO communications protocols, education, training, and schedules.

Requirements

Broad-based business experience within the healthcare/managed care environment

Nice To Haves

Bachelor’s Degree in Health Care Administration, Nursing, Business, or related field preferred
Valid Driver’s License

Responsibilities

Works directly with providers to ensure they are serviced, maintained, and educated on all policies and procedures in an efficient and professional manner
Manages collaboration with other departments and outside entities to meet identified needs of the providers and their patients, while also ensuring that other staff cooperate with these entities
Provides positive, supportive communication to providers at all times
Provides content for the Provider Insider Newsletter to ensure approved messages and communication comply with Provider Notification requirements
Acknowledges any grievances and complaints within 1 business day of notice and resolves the issue within 30 days. All notes and communication are clearly documented within the appropriate workflow to ensure adequate tracking of the resolution of the complaint
Assists with ensuring providers are compliant with the NCQA requirements regarding availability and access standards and also evaluates the standards to ensure they address the requirements outlined by NCQA
Facilitates provider surveys and communications required for NCQA compliance
Provides education, coaching and guidance to providers regarding HEDIS measures, CMS programs and any other quality initiatives for members
Gathers provider opt-in forms for various contracted entities that fall under HOA (Medicaid CMOs, Tricare, PHS/CI, etc.)
Assists Contracting, Credentialing and Network Management in loading new providers and completing contract/credentialing files
Works with Network Management to ensure provider updates are sent for processing timely and ensures updates are performed accurately within the system
Assists in research and problem resolution on issues related to claims processing incorrectly and works with the Claims Department to find resolution
Reviews claim reports for denials and works with providers to improve claim submissions and provider data updates to ensure accurate claim adjudication
Creates, audits, and distributes provider reporting as necessary
Facilitates messenger model activities with health plan partners
Encourages web-site and provider portal utilization through education and training to ensure providers can maximize the website and portal to best service their practices and patients
Maintains provider and patient confidentiality at all times
Keeps current in changes and trends that affect the Managed Care Industry
Maintains regular and predictable attendance
Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
Works to encourage and promote Company culture throughout the organization
Other duties as may be assigned