Description
Summary- Senior Provider Relations Account Specialist is responsible creating, implementing and evaluating training programs for Provider Relations Staff, as well as training needs for internal departments with the roll-out of new programs from Provider Network Operations.
- Monitoring or provider performance including but not limited to overseeing accurate and current provider databases, provider training, education and information to providers and responding to all provider related inquiries
- Duties also include Facility Site Review (FSR) management to ensure Provider offices are prepared for site audit.
- Responsible for creating, implementing and evaluating training of Provider Relations staff.
- Assist with policy and procedure interpretation, research, analyze and resolve complex problems dealing with claims, appeals, grievances and eligibility
- Functions as a lead among other department staff.
- Acts as a resource in resolution of very complex or escalated issues.
- Supports and/or participates in provider contract negotiations.
- Represents Manager, Provider Relations when Manager is not available.
- Creates and maintains a positive working relationship with all contracted Providers as assigned
- Providers will include Participating Physician Groups (PPG's), Hospitals, Ancillary, Specialty Health Plans, Sub-Contracted Health Plans and Long Term Care Providers
Qualifications
- Working knowledge of the compliance/regulatory requirements of DMHC, DHCA, CMS, NCQA, HEDIS, HIPAA, etc
- Experience in managed health care environment with exposure to provider contracting, servicing, benefits interpretation and internal operations of provider relations functions required
- Education: Bachelors Degree in Health Services, Health Care/Hospital Administration, a related field or any combination of education and/or equivalent
- Minimum 8 years progressive provider services/relations experience with a health plan or medical group
- 3 years creating training programs and training staff
- Excellent oral and written communication skills and presentation skills
- Strong analytical and problem solving skills
- Demonstrated ability to deliver training and conduct meetings to varied audiences
- Experience with Microsoft office applications