Act as a liaison between HN1, provider and contracted health plans concerning all aspects of network participation and provider relations.
· Manage, guide and support the activities of Provider Relations Call Center staff that support the Specialty Provider Networks, including: Provider Communications (e.g. Payor and other audits; and QI programs, initiatives and committee meetings, etc…)
· Support and manage Provider Relations Call Center activities to maintain SLA requirements.
· Must be familiar with various aspects of billing, claims adjudication and claims payment for the specialties assigned. This should include, but may not be limited to CPT Coding, ICD Code Sets, and CMS Fee Schedules.
· Maintain strong working relationships with all contracted specialty/primary care/ancillary providers, acting as their key support in all aspects of their contractual relationship with HN1.
· Advise senior management of both the strengths and weaknesses in the PN and institute or recommend changes which better serve the organization and its assigned membership.
· Manage and maintain a close working relationship with the TPA operations staff and work interdependently with each Department: Claims, Utilization Management, Credentialing and Provider File Maintenance.
· Develop and maintain familiarity with the managed care industry, such as availability of
outside sources of information, statutes affecting HN1 business, current industry trends, and general services/locations of major non-contracted providers.
· Must support company philosophies, objectives, decisions and policies.
· Ensure adherence to department and organizational standards, policies and procedures, including HIPAA.
· Ensure integrity of data entered into Company systems and/or databases.
· Two or three year’s extensive working background in the managed care industry.