Provider Relations Consultant

Must Have: 

• Previous Provider Relations Experience in Massachusetts

• Experience with Medicare and Medicaid reimbursement methodologies

• Must have valid driver’s license and access to a car- travel 50% of time in assigned territory

• Previous health insurance industry experience

• Live in the Massachusetts area

Job description:

You’ll act as the primary liaison between our contracted medical providers and our internal departments, such as Claims, Benefits, Audit, Member and Provider Enrollment and Clinical Services. In this role, you’ll identify and resolve multiple issues and work closely with the leadership team to problem-solve and report trends.

• Investigate, document, track and assist with claims resolution.

• Interact with various operational departments to assure accurate and timely payment of claims in accordance with our company's policies and procedures.

• Identify system changes impacting claims processing and work internally on resolution.

• Identify systematic issues and trends and research for potential configuration-related work.

• Analyze trends in claims processing and assist in identifying and quantifying issues.

• Run claim reports regularly to support external provider visits.

• Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach,

• Act as liaison for all reimbursement issues with providers, including facilitating the resolution of complex contractual and member/provider issues while collaborating with internal departments as necessary.

• Provide general education and support on our company's products, policies, procedures and operational issues as needed.

• Manage the flow of information between internal departments and providers to ensure timely communication full understanding regarding Insurance changes and updates.

• May outreach to providers according to our company initiatives.

• Facilitate interdepartmental collaboration to resolve complex provider issues.

• Identify system updates as needed and complete research related to provider data in Onyx and Facets.

• Process reports as needed to support provider education, servicing, credentialing and recruitment.

• Ensure quality and compliance with state agencies and NCQA.

• Other responsibilities as assigned.

• Ability to understanding of and implement relevant company policies and procedures.

• Regular and reliable attendance is an essential function of the position.

Qualifications:

Education:

• Bachelor’s degree in business administration or a related field or an equivalent combination of education, training and experience is required.

Experience:

• Two or more years of progressively responsible experience in a managed care or healthcare environment is preferred.

• Experience with Medicare and Medicaid reimbursement methodologies.

• Understanding of provider coding and billing practices.

• Certification or Conditions of Employment:

Competencies, Skills and Attributes:

• Experience with ICD-10, CPT/HCPCS codes and billing claim forms

• Ability to work in a team environment, prioritize and manage multiple tasks, be flexible, and work independently

• Excellent organizational skills

• Proven expertise utilizing Microsoft Office products

• Effective communication skills (verbal and written)

• Strong follow-up skills 

• Must have valid driver’s license and access to a car.

*Sign-on bonus of $500 only when you apply via SSA & subject to remaining in role for 91+ days

*Sign-on bonus of $5000 only when remaining in role for 91+ days

Next Steps:

• Recruiter Screen

• Manager Screen

• Additional Team Member Screen