Sr Account Manager Provider Complaints

HealthFirst•New York, NY

About The Position

The Sr. Account Manager, Provider Complaints is an integral role that successfully manages escalated provider complaints as assigned. Reporting directly to the Sr. Manager, Complaint Resolution, they will be dedicated to (1) expediting the research of formally reported provider complaint (2) contacting providers to negotiate single case agreements and working through the various complaint details and (3) working with the appropriate internal stakeholders to close out all aspects of the complaints. In this role, the Sr. Account Manager, Provider Complaints deals with providers that require one-time resolution as well as serves as a single point of contact for Out of Network providers who have submitted a formal complaint. The Sr. Account Manager will drive results that increase provider satisfaction and reduce/eliminate repeat complaints from assigned providers. Efforts directly impact the improvement of CMS STAR ratings.

Requirements

Network Management / Provider Relations experience with Hospital, Physician, Ancillary and/or Behavioral Health providers
Familiarity with reimbursement methodologies (DRG, FFS, Capitation, APG, APC)
Experience with resolution of reported provider complaints
Managed Care operations experience working with various business partners to facilitate resolution (Legal, Regulatory/Compliance, Claims)
Resolution of root cause contributing to provider complaints
Work experience with MS Excel, Word, Power Point
Bachelor’s Degree from an accredited institution or equivalent work experience

Nice To Haves

Cross functional experience in working as a liaison to internal business partners
MS Visio
Critical thinking skills
Great attention to detail
Master’s Degree from an accredited institution

Responsibilities

Serve as internal point of contact for cross-functional internal departments and teams to ensure all provider complaints are addressed and resolved within established guidelines
Partners with Sr. Complaint Analyst, and performs root cause analysis, to ensure effective identification of contributing complaint issues
Performs all tracking and trending of activity on managing root cause inventory, as well as resolution of all root cause issues identified
Communicate complaint resolution results to key stakeholders
Drafts complex complaint summaries and speaking points to ensure Regulatory can effectively respond to external agencies regarding all aspects of a complaint
Makes recommendations on strategy and process improvement to drive successful outcomes of assigned complaints
Negotiates complex single case agreements and settlements with complex providers as needed to resolve a complaint
Works cross functionally to assist with resolution of complex claims related issues
Tracks all aspects of provider complaints and ensures all assigned deadlines are met
Serves as a subject matter expert for Delivery System Engagement on resolution of provider complaints
Additional duties as assigned