Job Description Summary

Qualifications

• A Bachelor’s degree in Healthcare Administration or related fields from an accredited university preferred and 5 years’ experience in a Provider Relations position, required.
• High degree of knowledge and working experience in medical terminology, provider billing practices, patient referrals, eligibility information, contracting, claims processing, and adjudication required.
• Ability to interpret various provider contract agreements and health plan documents, regulatory language, fee schedules such as diagnosis-related group (DRG), current procedural terminology (CPT), resource-based relative value scale (RBRVS), and healthcare common procedure system (HCPCs).
• Experience with California and Arizona credentialing application processes, Council for Affordable Quality Healthcare (CAQH) and Office of Inspector General (OIG) Sanctions for physicians, ancillary, dental, behavioral health, and hospital providers.
• Experience with various healthcare industry regulatory agencies and requirements, including but not limited to Center for Medicare & Medical Services (CMS), National Committee for Quality Assurance (NCQA), Department of Managed Health Care (DMHC), Department of Health Care Services (DHCS), preferred.
• Knowledge of medical terminology, claim fields, and the basics of HMO, PPO, EPO, POS, Self-Funded, Large plan products, and State/Federal payers Medicare & Medicaid.
• Knowledge of Medicare Fee Schedule and the design, CPT/HCPS service coding, understanding the provider types and their impact on claims and reimbursements.
• Effective problem-solving skills in resolving complaints and implementing effective solutions.
• High degree of proficiency in Microsoft Office applications including Outlook, Word, PowerPoint, Excel is required.
• Skill to establish and maintain professional relationships and communication with a wide variety of people and to work as a team member, and across departments within and outside the organization.
• Exceptional verbal and written communication skills with experience speaking and presenting to an external audience required.
• Ability to research and resolve technical issues and problems as they arise with minimal direction.
• Strong organizational skills; able to effectively prioritize assignments and competing deadlines in a fast-paced environment required. 
• Strong project & time management skills, knowledge of process improvement principles and programs preferred.
• Verifiable, clean DMV record and the ability to travel to various locations throughout the U.S. (mainly California and Arizona) up to 25% of the time.

Duties And Responsibilities

• Serve as first point of contact for provider relations question and issues. 
• Deliver new provider and office staff orientations and continued education of existing providers to ensure company programs, initiatives and processes are being effectively communicated and followed.
• Proactively research and resolve provider issues including but not limited to claims submission, processing, and payment; contracting details; provider tools; and Utilization Management and other protocols.
• Review existing provider education materials and make recommendations around necessary modifications and changes as contracts, plans and business needs change.
• Provide continuous provider education and onboarding orientation training to all network providers through conversations, tools or aides, as well as internal education of claims, customer service, utilization management and account management staff. 
• Resolve provider access issues through education and provider contracting.
• Achieve a minimum of 15 outbound calls per day (75 outbound calls a week) to establish consistent and strong relationships with provider offices.
• Adhere to department standards for call answer and issue resolution requirements.
• Document all communication, account notes, and contact information in the Health Claims Processing System (HCPS), spreadsheets, etc.
• Identify concerns/issues and opportunities for improvement, research and resolves issues for provider offices, and provide accurate and timely answers.
• Provide feedback and guidance to resolve provider questions and assist with interpreting customer feedback and coordinating resources and responses.
• Assist in the process of negotiating fees that align provider needs and WGAT and PCMI business objectives as directed by Manager, Provider Contracting & Reimbursement and/or Provider Contract Analyst.
• Educate providers on fee structures to ensure collaborative agreement and understanding of health plan services and the fees associated with various contracts.
• Coordinate escalated claim disputes and all necessary research timely and effectively according to department standards. 
• Acts as Subject Matter Expert for WGAT and Pinnacle’s products and how they relate to the providers’ Agreement, business needs and goals.

• Assist with developing network or project/program objectives, which include timelines, materials, and other project requirements. 
• Internal network liaison for other departments (i.e. Utilization Management, Claims, Eligibility, Customer Service, etc.).
• Assist in the maintenance of medical and dental contract fee schedules and Usual and Customary (U&C) tables on HCPS.
• Responsible for pricing claims utilizing different medical networks for claims outside of the standard California and Arizona pricing and contracts.
• Load Preferred Provider Organization (PPO) network from all third-party vendors as applicable to the appropriate health benefit plan.
• Assist with the development of network recruitment and retention strategies to ensure the retention and maintenance of high-quality contracted providers.
• Conduct data-driven analytics regarding network providers, IPA/medical groups, and hospitals to drive critical discussions and decisions to deliver established quantifiable goals and targets.
• Completes the end-to-end processing and documentation of provider and ancillary credentialing for California and Arizona credentialing applications, reviews the Office of Inspector General (OIG) Exclusion database and Primary Source Verification to complete credentialing process of providers.
• Implement strategies with providers to improve provider performance. Customize special education needs for providers as well as delivering strategic communications to assigned providers as necessary.
• Maintain accurate collection of key provider data updates, pricing tables and up to date network files related to provider contracts and credentialing for all network relationships under WGAT and PCMI.
• Processes new provider credentialing following WGAT and PCMI’s guidelines and processes, ensuring all information is complete and accurate.
• Manage the Provider Relations telephone queue, adequately respond and resolve incoming calls and emails in a timely manner as dictated by department standards.
• Monitor, analyze, and report trending provider issues to management and assist in closing care gaps and improve access to care on a monthly basis or as directed by Manager of Provider Contracting & Reimbursement.
• Monitors and resolves provider directory inaccuracies relative to provider networks developed by WGAT and PCMI.
• Communicates changes regarding provider information to appropriate cross-department teams to ensure timely updates of systems and directories.

• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, being self-accountable, creating a positive impact, and being diligent in delivering results.
• Work in collaboration with cross-functional teams to continually improve operational processes and procedures as it relates to effective network and provider management.
• Partner with management to design, update and/or improve tracking and reporting.
• Identify, initiate and implement at least one process improvement and/or innovation annually.
• Identify potential process problems and suggest solutions to prevent a breakdown in the process or communication.
• Create and document a minimum of one Standard Operating Procedure (SOP) annually.
• Maintain a clean DMV record and the ability to travel to locations throughout the U.S. (mainly California and Arizona) up to 25% of the time.  
• All other duties as assigned.

Physical Demands/Work Environment