Provider Services Representative 2 - Renown Health

Position Purpose

This position functions as the liaison between Hometown Health and the provider and their respective office staff. The incumbent cultivates positive, effective working relationship with providers, vendors, internal departments, leadership, and other liaisons third party payers in a manner that produces resolutions, meeting plan standards, while upholding provider satisfaction. Coordinates regularly scheduled meetings with contracted providers and all Hometown Health internal departments to resolve service issues, payer rejections, denial trends, contract issues, and other pertinent issues having negative impact on revenue cycle and viewpoints. Maintaining expanded knowledge base of Hometown Health contracted payer/product lines, payer policy and billing requirements. This position associates and instructs provider offices on the high-level resources and capabilities of our web-based portal EpicCare Link.

Nature and Scope

This position communicates with Network Services Director and other appropriate management staff viewpoints, and perceptions of Hometown Health’s provider community. The information gathered will be used in policy formulation and process improvement opportunities. This position provides the opportunity to be knowledgeable of benefit structures for all product lines as well as payment policies while maintaining good working relationships with our provider community.

• Develop and manage provider relationships demonstrating a service approach while adhering to HTH/Renown Health policy and procedures.

• This position provides communication, education, to providers in regard to HTH customers’ feedback/concerns, authorizations requirements, reconsideration requirements, J-Code Fee Schedule updates, benefit plan updates, and finance/policy updates as they occur.

• Performs financial analysis for financial impact on provider EOPs, resolve trends, underpayments and other payer issues that impact provider reimbursement.

• Coordinates internal and external resources to resolve issues/problems for providers

• Serves as a point of escalation for leadership to resolve outstanding issues with financial impact.

• Identifies/researches and resolves issues including claims, fee schedules, benefit/eligibility, reconsiderations, authorizations, provider and member grievances and complaints.

• Internal collaboration with Contract Specialist on execution and implementation of contracts; check CPT codes and run accuracy evaluation on fee schedules.

• Assists Contract Specialist in monitoring the providers’ performance based on utilization patterns and other quality standards.

• Organize and facilitate all educational materials and/or classes to contracted providers and their staff including on site presentations for EpicCare Link or other topic as needed by HTH strategic plan.

• Conducts in person site visits to applicable provider offices.

• Coordinates regularly scheduled meetings with provider office visits to facilitate relationship, to resolve service issues, payer rejection denial trends, contract issues, and other pertinent issues having negative impact.

• Collaborates with the Quality Care Program in engaging the provider community to participate in revenue driven and quality measure program.

• Vendor contract management and oversight; arranging quarterly meetings, assign vendor with projected quarterly outcomes to be reported out on, compliance standards regulation tracking, annual reporting to Delegation Oversight Coordinator.

• Communicate and collaboration with HTH departments to resolve and address identified provider issues/feedback, educational opportunities, and quality of care concerns to improve our overall quality as well as the member and provider experience.

• Contribution in process improvements constructed on response from providers to improve the quality of care of HTH members and the service level of the provider.

• Create, maintain, and manage the design and content of the external Provider page on website including the reviewing and updating the Administrative Guidelines and other provider facing content.

• Supports Network Services leadership with other duties as assigned to support team initiatives.

• Demonstrate excellent initiative and judgement. Works independently applying effective approaches to task prioritization, time management, meeting deadlines, and delivering outcomes/resolved issues.

Incumbent must show ability to gain additional educational, training and communication skills to educate and train providers and their staff. Ability to promote individual and team excellence with our provider community while maintaining confidentiality. Strong organizational skills to maintain efficiency in a busy environment. Working knowledge of health insurance and health maintenance organizations methods with the ability to prioritize projects.

This position does not provide patient care.

Disclaimer

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Minimum Qualifications
Requirements - Required and/or Preferred

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing, and speaking English. Two-year college degree from an accredited college. This requirement can be substituted by two years of provider office or managed care experience in the health care industry.

Experience:

Preference given to those applicants with three years' experience in a position which involved extensive customer service and/or training skills. Working knowledge of managed care principles is preferred. Requires one-year computer experience with preference given to those applicants with Access, Excel and/or Word.

License(s):

None

Certification(s):

None

Computer / Typing:

Must possess, or be able to obtain within 90 days, the computers skills necessary to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc. Type 35 WPM.

PI242132516