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.
Carle Foundation Hospital