Provider Relations Specialist

Carle Foundation Hospital Champaign , IL 61822

Posted 2 weeks ago

  • Meets/Works with providers and their office staff and Health Alliance staff to explain policies and procedures and to resolve operational issues.

  • Provides assistance, clarification, and resolutions to problems/concerns for various types of providers, including billing, reimbursement, referrals, authorizations, etc.

  • Follows up with written documentation to appropriate internal staff and providers.

  • Provides written explanation and follow up as needed for provider/member complaints.

  • Attends Health Alliance/Partner Steering/Operations Meetings as needed.

  • Responsible for ongoing education and communication with providers including physicians, hospitals, ancillary, extended networksand tertiary providers.

  • Provides in-services on billing, reimbursement, referrals, authorizations, website, etc.

  • Communicates and provides written information regarding new products and new groups.

  • Writes and distributes inforMED newsletters.

  • Develops, plans, organizes and/or conducts orientation, training, and education meetings/programs.

  • Educates and assists providers in claims submissions.

  • Interprets various reports.

  • Reports provider status information and summarizes changes in the network to internal departments and external organizations.

  • Works with key providers and/or risk partners in maintaining an adequate provider network by identifyingprovider network gaps in assigned territories.

  • Works with providers to encourage open panels when provider closes panel.

  • Point of contact for additions or deletions to existing contracted provider groups and individuals.

  • Responsible for proofing and updating provider directories for assigned territories.

  • Acts as the point person for provider demographic, contract and systemchanges.

  • Develops, reviews, updates and maintains the provider manual.

  • Assists in the development of operational policies and procedures related to providers.

  • Assists in delivering key executed contracts.

  • Ability to understand and ensure compliance with contract language and limitations.

  • Works with Provider Partners to identify potential providers through needs assessment process.

  • Remains current in managed care industry trends by completing classes in Health Alliance University,attending educational seminars and maintaining relationships with collegues in the field.

  • Responsible for maintaining and updating PRS tracking systemon a daily basis.

  • Exhibit commitment to continuous improvement through self-development and improvement.

  • Adheres to and enforces Health Alliance Medical Plans and Carle administrative and departmental policy and procedures.

Serves as the liaison between health care providers and Health Alliance; responsible for provider orientation, ongoing education and problem resolution. Builds relationships with providers and their office staff by meeting face to face on a routine basis to ensure open communication between health plan and providers. Ensure provider demographic information is correct and up-to-date in assigned territory.


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