Senior Provider Network Representative
About The Position
The Senior Provider Network Representative develops, contracts, maintains, and enhances relationships with facilities and physicians to drive business results. The role represents providers in matters involving contractual arrangements, compliance, regulatory requirements, credentialing, claims, provider files, and administrative policies and procedures. The position may serve sponsors and other large provider entities across multiple boroughs. The representative manages relationships with provider organizations, addresses provider service needs and escalations, supports contract administration and provider data quality, and coordinates work related to credentialing, provider rosters, rates, and network strategy. The role also contributes to member growth and medical cost objectives.
Requirements
- Bachelor’s degree in health care administration, business, or an equivalent combination of education and work experience in managed care or health care.
- At least five years of experience in health care, including at least three years in provider/payor contracting.
- Extensive experience developing contract types, fee arrangements, and other contract terms, and developing and recommending potential solutions to contract issues.
- Proficiency in Microsoft Office software, including Word, Access, and Excel.
- Ability to travel efficiently and continuously to and within the assigned geographic area.
- Strong organizational and project management skills.
- Understanding and sensitivity to the multicultural values, beliefs, and attitudes of internal and external contacts.
- Ability to demonstrate behaviors aligned with the organization's vision, mission, and values.
Responsibilities
- Develop and retain effective relationships with physician and business leadership of key physician groups and delivery systems in designated geographic areas to drive business results.
- Mentor team members, manage escalations, and oversee more complex and high-priority contracted health systems.
- Conduct regular service visits to meet provider service needs, resolve issues, educate providers and staff on policies and web-portal usage, collect credentialing information, and review HEDIS information.
- Respond to inquiries from assigned providers, resolve issues, and assist colleagues with complex provider inquiries.
- Implement and manage relationships with large, high-profile physician groups, IPAs, and hospital systems to achieve positive business results.
- Coordinate the exchange and updating of data and follow-up for credentialing delegation rosters, provider-file functions, and provider-rate implementation initiatives.
- Manage delegated provider rosters to ensure data accuracy and timely processing.
- Contract with community- and hospital-based physicians and ancillary providers.
- Perform duties related to regulatory compliance and organizational requirements.
- Facilitate and manage Single Case Agreements as required.
- Conduct monthly calls with the provider network to ensure compliance with IPRO/Access and Availability.
- Identify potential claims and systems trends and correct root causes of provider-systems data issues.
- Monitor contracts to ensure contract-administration objectives are achieved and oversee provider data quality assurance.
- Chair regular contract relations meetings with key groups.
- Coordinate contract-management strategies with the hospital and ancillary lead to support the organization's network strategy.
- Assist with developing and executing strategies for member growth and achievement of medical cost targets.
- Perform other duties as assigned.
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What This Job Offers
Job Type
Full-time
Career Level
Senior
