Provider Relations/Network Services Representative - SHCN
Position Purpose: The Network Services Representative has daily interaction with internal departments as well as conversations with the Provider Network. Frequent travel to Providers’ offices is required. This position requires initiative and assertiveness when negotiating contracts or letters of agreements, as well as when dealing with provider issues and concerns. This position will write draft contracts, amendments, letters of agreement, provider correspondence and other documents as required. This position requires knowledge of all elements of Steward Health Choice plan processes and policies to enable education of the providers. This position will be responsible for financial performance within an assigned service area. Sound and objective decision making must be exercised in all interactions with providers and internal departments.
Establish professional and effective face-to-face, written, and telephone communication relationships with assigned providers.
· Travel to provider and facility locations to identify, discuss, and resolve various issues, respond to provider requests for research and resolution of complaints
· Disseminate/communicate information to internal colleagues and communicate significant or important information to appropriate departments
· Consult with Medical Services to ensure providers are following proper medical procedures
· Interact with Reimbursement Services regarding payment schedules and rates of reimbursement
· Perform initial orientations and ongoing in-service/education to providers
· Familiarize key staff with Steward Health Choice policies and procedures
· Inform providers of policy changes and/or new policies
· Ensure providers are following proper medical procedure and referral, information/authorization, covered service guidelines, and submission of claims.
· Assist in establishing financial and quality targets for medical expenses within the assigned service area and the ongoing monitoring and educating of providers who are not satisfying such targets.
· Collaborate with assigned providers to close gaps in care and to improve member satisfaction
· Build relationships of trust with providers through timely follow through and through a customer service focus
· Timely complete department initiatives that relate to assigned providers
Initiate, coordinate, and negotiate contracts with physicians, hospitals, and ancillary in an assigned area to assure adequate medical services for Steward Health Choice members. Maintain and ensure provider demographic information is complete and up to date.
· Analyze and evaluate network coverage to identify network needs
· Review contracts and proposals to determine proper reimbursement
· Negotiate fees and create contracts
· Obtain required information and documents from providers to begin the credentialing process
· Identify and submit updates and corrections to demographics as they are identified or as received from the provider
· Network coverage is analyzed and evaluated to identify network needs.
· Contracts and proposals are submitted to providers and reviewed. Acceptable reimbursement parameters are determined with management prior to execution of the contract.
· A signature is obtained on a contract prior to the commencement of the credentialing process
· Other required documentation is obtained prior to the commence of the credentialing process
Assist with applicable accreditation organization and regulatory compliance responsibilities.
· Development and distribution of Provider Manual
· Development and distribution of Member Handbook
· Complete Compliance Director directives that affect assigned providers
· Assist the Network Services Department in complying with state and federal laws and regulations.
Perform other duties as assigned
Equal Opportunity Employer Minorities/Women/Veterans/Disabled
· High school Diploma/GED is required
· College degree is preferred
Years of Experience:
· A minimum of two years of health plan experience is preferred
Work Related Experience:
· Knowledge of Medicaid and Medicare Programs is preferred
· Organizational skills
· Strong presentation and oral and written communication skills
· Proficient ability to use Microsoft Office products include Excel and Word
· Ability to negotiate and implement provider contracts
· Strong customer service skills and techniques
· Ability to plan and organize