Note: The job is a remote job and is open to candidates in USA. CareMore Health is a healthcare organization focused on delivering managed care services. The Network Relations Consultant is responsible for engaging and developing relationships with network physicians, supporting provider education, resolving claims and administrative issues, and improving PCP performance, access, and quality metrics.
Responsibilities
- Develops and maintains positive provider relationships with provider community by regular on-site visits, communicating administrative and programmatic changes, and facilitating, education and the resolution of provider issues
- Serving as a knowledge and resource expert regarding provider issues impacting provider satisfaction, researches and resolves complex provider issues and appeals for prompt resolution
- May be responsible for coordinating non-negotiated contracts for new and existing providers as needed
- Researches, analyzes and recommends resolution for contract dispute, non-routine claim issues, billing questions and other practices
- May participation in Joint Operation Committees (JOC) of larger provider groups
- Coordinates communication process on such issues as administrative and medical policy, reimbursement and provider utilization patterns
- Conducts seminars to support the understanding of managed care policies and procedures
- Identifies network access and deficiencies and develops recruitment and contracting strategies
- Coordinates and conducts provider training including developing and distributing provider relations materials
- Responsible for providing quality, accessible and comprehensive service to the company's provider community
- Provide assistance regarding education, contract questions and non-routine claim issues
- Coordinates communications process on such issues as administrative and medical policy, reimbursement and provider utilization patterns
- Coordinates prompt claims resolution through direct contact with providers, claims, pricing and medical management department
- Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery
- Tracks and conduct provider refresher training
- Researches issues that may impact future provider negotiations or jeopardize network retention
- Consistent PCP visits focused on:
- PAHAF completion, STARS gaps closed
- HCC Re-capture rate
- PCP referrals
- Model of Care
- Portal usage/training Referrals and authorizations
- New PCP on-boarding
- Issue identification & resolution:
- Claims
- Referrals and authorizations
- G&A
Skills
- Requires a Bachelor's degree
- Minimum of 3 years of customer service experience including 2 years experience as a Network Management Rep; or any combination of education and experience, which would provide an equivalent background
- Travels to worksite and other locations as necessary
Benefits
- This position is bonus eligible based on individual and company performance.
- Remote - Full Time
Company Overview