1.Responsible for working collaboratively with the Director of Network Management and Medical Management team to ensure network growth and development initiatives are being met and are networks are operating within budgets.
2.Responsible for the preparation and negotiation of provider contractual agreements during Primary Care, Specialty and Ancillary recruitment projects.
3.Responsible for New Provider and Staff Orientations and continued education of existing providers to ensure company programs and initiatives (i.e. P4P, HCC, Vital Care, Encounters, etc.) and process is being effectively communicated and followed by the provider network. Also, to ensure provider is effectively utilizing company tools (i.e. REA, iCode, etc.) available to them.
4.Responsible for the oversight of their assigned networks to ensure network provider deficiencies are being met and working closely with their assigned Network Support staff and Medical Management counterparts to ensure network needs/changes are being effectively addressed and communicated both internally and externally.
5.Maintaining and updating the appropriate databases and department tools with current information.
6.Responsible for the coordination, receipt, and review and processing of all provider contracts, credentialing, and provider correspondence to ensure the department has obtained proper signatures and documentation to effectively process newly recruited or existing providers.
7.Responsible for timely and accurate completion of PACF's related to incoming documentation received from providers regarding changes to their demographic information in the credentialing and provider network databases.
8.Responsible for submitting provider profiles to the Health Plans, conducting required follow-up to ensure Primary Care Physicians are active in health plan databases and obtaining health plan assigned provider identification numbers in affiliation with Regal. Also, responsible to ensure terminated PCP's are effectively terminated and enrollment retention efforts are followed.
9.Responsible for the review of Health Plan Directories for assigned network/s as well as communication of adds/terminations/changes to the health plan.
10. Assist with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate policy.
11. Daily interaction with regional providers and at minimum quarterly visits to PCP and Specialist offices unless visit is warranted at earlier.
12. Ensure contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
13. Internal network liaison for Database, Claims, Customer Service, Medical Management, and Quality Management Departments.
14. Perform on-site visits (as required) to physicians, physician groups, hospitals and ancillary providers.
15. Facilitate the quarterly Joint Operations Meetings with contracted providers and office staff.
16. Oversight of database maintenance and accuracy through use of audits.
17. Ensure accurate and timely data reporting requirements are being met including eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed days utilization, encounter data and audit compliance.
18. Know and follow the Employee Handbook policies and procedures.
19. Maintain patient confidentiality so that HIPPAA compliance is observed at all times.
20. Other duties may be assigned as needed.
Distribution of work:
1.Minimum of 2 years relevant work experience in Network Management, Contracting or Provider Relations in a managed care setting, health plan or large medical group administration.
2.Knowledge of contracting principles/tools.
3.Excellent verbal and written communication skills.
4.Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
5.Must be able to travel within service area and have valid driver's license and insurance