Job Description Summary

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The Network Relations Consult is responsible for assigned network PCP performance including PAHAF completion, AWV and Star rating of 4 or above.

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How will you make an impact & Requirements

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Network Management Consultant: will own individual performance engagement and on-the-ground relationship development for new and existing MDs.

• 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.

Requirements:

• 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.

Quality and AWV

•Consistent PCP visits focused on:

•PAHAF completion, STARS gaps closed

• HCC Re-capture rate,

•PCP referrals

Provider Education

•Model of Care

•Portal usage/training Referrals and authorizations

•New PCP on-boarding

Issue Resolution

Issue identification & resolution:

•Claims

•Referrals and authorizations

•G&A

Compensation: $67,896K - $90,000K annual salary & bonus eligible

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