Provider Relations Specialist

State of Maine•Augusta, ME

1d•$21 - $29•Onsite

About The Position

This position reports to the Provider Services Manager and is responsible for developing and maintaining expertise in an assigned set of provider types and policies. The individual will provide support for these assigned areas while also developing knowledge of and supporting policies shared across the team. The position will also require a working knowledge of MaineCare member eligibility requirements and classifications to support accurate and effective claims analysis. The individual must be able to manage multiple and evolving priorities in an organized and efficient manner while maintaining composure, professionalism, and sound judgment when addressing challenging situations.

Requirements

A four (4) year combination of training and experience providing a knowledge of health care administration and community health services.
A proven ability to investigate and resolve complex medical insurance claims billing issues, and a thorough knowledge of MaineCare provider policies, programs, guidelines, procedures, and processes or similar knowledge in a commercial health plan environment
A demonstrated ability to develop and deliver adult training programs to diverse audiences, including comfort with Microsoft PowerPoint
Strong analytical and problem-solving skills, including comfort with Microsoft Excel
Ability to foster collaborative working relationships with both internal and external stakeholders
Ability to work independently on multiple projects while maintaining progress on daily work.

Nice To Haves

Experience with and knowledge of the Medicaid program and/or other health and human services programs serving low-income populations
Lived experience with Medicaid and/or other health-related social needs common to individuals and families receiving Medicaid coverage

Responsibilities

Interpreting and applying MaineCare policies, with a primary focus on the MaineCare Benefits Manual, and providing clear, accurate, and timely guidance to MaineCare providers. This includes communicating policy requirements, clarifying applicable guidance, and assisting providers in understanding their responsibilities and compliance obligations. The position will ensure that provider communications are consistent with established MaineCare policies and procedures and are presented in a clear and professional manner.
Researching complex claims data by exporting claims data onto spreadsheets, analyzing claims data, assessing root cause and remediation, and assisting providers with resolution.
Collaborating effectively with internal teams across the Office of MaineCare Services (OMS) and the Department of Health and Human Services (DHHS), as well as external vendor partners, to research, analyze, and resolve complex claims issues. This includes working closely with teams responsible for claims processing, policy development and interpretation, utilization management, rate setting, and prior authorization to identify root causes, clarify requirements, and develop appropriate and timely resolutions. The position will also participate in cross-functional workgroups and project teams supporting large-scale initiatives, system changes, policy implementations, and other organizational priorities as needed.
Utilizing strong verbal and written communication skills to develop and present provider training and educational materials on MaineCare policy and claims and billing. Training may be for individual providers or for groups, both on-site and virtually.
Assisting providers to determine the appropriate provider type and specialty under which to enroll with MaineCare, as determined by the services the provider renders.
Representing OMS and the Department by participating in provider forums, stakeholder groups, provider association meetings, and other external meetings to both share policy and billing information and to gather information about policy or billing issues.

Benefits

13 paid holidays
3+ weeks of vacation leave annually
12 days of sick leave per year
Health Insurance Coverage – The State of Maine pays 85%-95% of employee-only premiums
Health Insurance Premium Credit – Participation decreases employee-only premiums by 5%
Dental Insurance – The State of Maine pays 100% of employee-only dental premiums
Retirement Plan – The State contributes the equivalent of 14.06% of the employee's pay towards the Maine Public Employees Retirement System (MainePERS)
Gym Membership Reimbursement – up to $40 per month
Health and Dependent Care Flexible Spending Accounts
Public Service Student Loan Forgiveness
Living Resources Program – employee assistance program
Six weeks of fully paid parental leave
Voluntary Deferred Compensation – MaineSaves 457(b) account