Under the supervision of the Provider Relations Manager, this position is responsible for the continual development and management of an assigned network or networks through provider orientation and provider education as well as the development and maintenance of relationships with physicians, providers and practice managers within an assigned provider network. Applicant must reside in New Mexico (Albuquerque or Santa Fe)
- Develop and maintain strong relationships with assigned network physicians/providers through routine visits, in-services, teleconferences and correspondence.
- Responsible for prioritizing assigned network needs in regards to provider types and numbers, and marketing to potential providers via the development of marketing materials, direct phone calls, correspondence and direct visits.
- Provide initial orientations to new providers/physicians and their staff in order to ensure compliance with Plan's rules and regulations.
- Continually assess the needs of additional and/or ongoing education of current providers/physicians. In addition, responsible for determining appropriate level of re-education as well as the appropriate medium for re-education (i.e., correspondence, full re-orientation, topic-specific re-orientation, large in-services with all network providers, or teleconference).
- Determine trends within claims issues and appeals and works with appropriate staff to correct ongoing issues whether internally (i.e., system issues, processing errors, etc.) or as part of ongoing education with providers.
- Educate providers through provider profiling and analysis on HEDIS or other measures.
- Educate providers on compliance expectations with applicable federal and state rules and regulations, and plan policies and procedures.
- Assist in the development of the department through the development/enhancement and implementation of new departmental process, policies and/or procedures.
- Attend meetings for Plan as necessary.
- Follow the CHRISTUS Guidelines including, but not limited to the Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI), in addition to other applicable federal, state, and accreditation regulations.
- Travel requirement 90%.
- Bachelor degree preferred
- Analytic ability to organize and prioritize work to meet deadlines.
- Proficient in Microsoft Word and Excel
- Excellent written and verbal skills required
- Good judgment, initiative and problem solving abilities
- Ability to handle and resolve complex issues with little assistance
- Ability to perform multiple tasks simultaneously
- Ability to communicate effectively
- Two to three years network management or managed care experience preferred
- Prior experience working with TRICARE, Texas Medicaid, Medicare, Medicare Advantage, and/or commercial products is highly desirable
C. Licenses, Registrations, or Certifications: