Provider Network Management Relations Executive

Presbyterian Healthcare Services•Remote Workers New Mexico, NM

7d•$51,210 - $78,166•Remote

About The Position

Presbyterian is hiring a skilled Provider Network Management Relations Executive to join our team. This is a full-time, exempt position based remotely for workers in New Mexico. The role involves building careers and making a difference by providing oversight of network strategies and relationship development activities for assigned providers. This includes individualized planning, training, and development of providers to align with Presbyterian's clinical quality initiatives. The position will also provide the framework for physician/provider performance reporting to assist with objective and quantitative analysis of clinical quality performance measures. The Network Relations Service Executive is accountable for proactively identifying issues, resolving disputes, and coordinating resolutions, acting as a liaison between the provider of service and the health plan.

Requirements

Three years experience in provider relations, provider contracting, claims processing, or customer service in a healthcare organization.
Strong working knowledge of risk sharing programs and different reimbursement methodologies i.e. capitation, DRG, Relative Value Systems, etc.
Must demonstrate strong verbal, written communication, and presentation skills with strong interpersonal and negotiations skills and ability to interface with providers.
Must also possess strong facilitation, organizational, and personal computing skills

Responsibilities

Provides oversight of network strategies and relationship development activities for assigned providers including individualized planning, training and development of providers to align with Presbyterian s clinical quality initiatives.
Will provide the framework for physician/provider performance reporting that will assist providers with objective and quantitative analysis of clinical quality performance measures.
The Network Relations Service Executive is a professional accountable for proactively identifying issues, resolving disputes, and coordinating resolutions.
Accountable for resolving complex problems, fielding general questions, and acting as a liaison between the provider of service and the health plan.
Collaborates and maintains relationships with providers and staff throughout Presbyterian to ensure an exceptional provider experience.
Develops and maintains cooperative working relationships between PHP, institutional provider and individual providers.
Provides education on quality initiatives, managed care, capitation, products, policies and procedures, reimbursement issues, referral/authorization process, etc.
Responsible for ensuring provider data integrity and accuracy by ensuring PIF s are completed timely and accurately and through a comprehensive review and validation of provider directory data.
Responsible for post payment validation of assigned providers to ensure accuracy of payment to the contract and corresponding fee schedules.
Resolves provider issues - claims, health services, finance, etc.
Stimulates and fosters professional development of the Network Relations Service Associates.
Supports Network Contracting strategies in an effort to preserve a robust provider network.
Serves as primary liaison between the provider and the health plan.
Maintains a general knowledge of health plan reimbursement methodologies.
Conducts provider visits based on established departmental goals, which will require 50-65% field contact.
Engages and supports leadership and peers by promoting and participating in department initiatives and being accountable for achieving business objectives.