Provider Network Specialist-Disputes (Remote Option-NC)

Partners Behavioral Health Management•Morganton, NC

8d•Remote

About The Position

Primary Purpose of Position: This position manages provider disputes, sanctions, and terminations and monitors the process for each of those ensuring a high-quality network to serve Partners members.

Requirements

Considerable knowledge of the laws, regulations and policies that govern the program
Exceptional interpersonal and communication skills
Strong problem solving, negotiation, arbitration, and conflict resolution skills
Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint)
Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws, rules and regulations to various situations; to apply regulations and policies for maintenance of consumer medical records, personnel records, and facility licensure requirements
Ability to make prompt independent decisions based upon relevant facts
Ability to establish rapport and maintain effective working relationships
Ability to act with tact and diplomacy in all situations
Ability to maintain strict confidentiality in all areas of work
Bachelor’s Degree in mental health, public health, social work, psychology, education, sociology, business or public administration and two (2) years of experience in a community, business, or governmental program in health-related fields, social work or education including experience in network operations, provider relations and management experience.

Nice To Haves

Master’s Degree with clinical licensure preferred.

Responsibilities

Oversees the follow-up and management of the provider dispute resolution process including notification letters of receipt of dispute, tracks timelines, maintains dispute log, conducts complete and thorough investigation of dispute, composes notification letter to provider related to that decision.
Visits provider agencies to facilitate communication & collaboration as needed
Obtains and maintains information regarding provider sanctions, terminations and disputes
Completes routine and ongoing contract compliance monitoring to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations
Interprets audit results, identifies trends/patterns that impact service/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree of quality through the Network Management Committee
Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the Member Engagement Department, the Program Integrity Department, the Quality of Care Committee, Network Management Committee or as indicated by another agency or departmental identified need
Serves as a subject matter expert and as a resource to other departments within the LME/MCO on provider issues specifically related to provider terminations, sanctions and dispute information when appropriate
Manages notification and tracking of provider contract terminations
Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed
Monitors all NMC issued sanctions for all providers
Maintains a log of all Medicaid and IPRS procurement contract terminations
Participates in oversight and monitoring reviews of the MCO including but not limited to NCQA and EQR reviews as appropriate.
Interpreting and assisting in developing and maintaining policies and procedures.