Provider Services Representative 25-00457

The Provider Services Representative – Hospital & Ancillary Relations is responsible for developing and maintaining strong and consistent relationships with the Health Plans hospital and ancillary Providers. Routinely communicate organizational policies, procedures and processes, regulatory updates. Anticipate and respond to Provider educational needs and conduct ongoing training integral to the implementation of improvement plans with hospitals and ancillary providers in order to meet quality metrics, service goals and compliance standards.

1. Conduct Provider orientation, continuous training and education to Providers and other stakeholders. Maintain accurate and timely log of Provider visits in compliance with NCQA standards and DHCS and CMS regulatory requirements.
2. Act as a Provider Advocate and liaison between Providers and IEHP departments in resolving Member, Provider and other stakeholder issues and concerns.
3. As assigned, visit Providers on a periodic basis, focusing visits strategically under the direction of the Hospital & Ancillary Relations leadership team, in alignment with quality initiatives and strategic priorities.
4. Monitor Provider needs through utilization and other available reports, quality data and cases. Support Providers through training and education to improve performance and satisfaction and close care gaps. and improve access to care.
5. Lead investigation and resolution of Provider grievances and health plan-related queries.
6. Promote Providers' electronic submission capabilities, including the timely and complete submission of encounter data, claims and utilization data related to quality metrics.
7. Communicate with Provider staff regarding pertinent issues, quality initiatives plan changes and facilitate Member and Provider case resolution.
8. Maintain a strong partnership with the appropriate departments to ensure constant, timely internal communication and coordination to support - Providers in their day-to-day operations.
9. Attend internal meetings and participate in external Provider meetings and focus groups as appropriate.
10. Assist Providers with interpreting manuals and reports, including eligibility, capitation, claims data, and quality information.
11. Communicate changes regarding Provider information to ensure timely update of systems and directories.
12. Coordinate with appropriate departments to address Provider inquiries concerning rate/service changes and claims disputes.
13. Assist with the development of the Provider Policy and Procedure Manual as requested.
14. Assist with the development of written communication to the Provider network as requested.
15. Assist with Joint Operations Meetings (JOMs) as scheduled and as assigned.
16. As applicable, review and verify compliance of the appropriate networks, identifying gaps and requesting Provider response and submission of appropriate credentialing and related information to close network gaps and meet regulatory requirements.
17. Review and verify Provider directory information and lead investigation and resolution of reported Provider directory inaccuracies.
18. Perform any other duties as required to ensure health plan operations and department business needs are successful.

REQUIREMENTS

Education & Requirements

• Three (3) or more years of experience with customer service required
• One (1) year of experience, including Hospital, Managed Care, Medical Group, IPA and HMO. Experience with managed care
• Bachelor's degree from an accredited institution required

Key Qualifications

• Working knowledge of Medical Group IPA and HMO operations
• Working knowledge of hospital and ancillary provider operations preferred
• Strong organizational skills
• Excellent written and verbal communication and interpersonal skills
• Microcomputer Applications (Microsoft Word and Excel, Access Preferred) for use in all aspects of an office environment
• Skilled data input
• Possess telephone courtesy with a high level of patience
• Excellent customer service skills
• Data entry involving computer keyboard and screens, automobile travel within the service area, distribution of reports and supplies to outside Provider offices

Commitment to Quality:
Our client is committed to incorporate Quality Program goals including, but not limited to, HEDIS, CAHPS, and NCQA Accreditation.

INDH