This position is responsible for the continual development and management of the Plan's overall provider network system through provider recruitment, provider contracting, and provider education, acting in a leadership role for Network Account Specialist and other staff within Provider Relations as well as the development and maintenance of relationships with physicians, providers and practice managers within an assigned provider network or networks. In addition, this position provides direct assistance to the Network Provider Manager and/or Director of Operations upon request and/or as needed and covers for Network Provider Manager during Manager's absence.
Fully develop and manage stable provider network(s) through ongoing provider recruitment and the maintenance of strong relationships with current network physicians, providers, and medical groups through routine visits, in-services, teleconferences and correspondence.
Work with internal staff, managers, and directors, geographical software, reporting tools and market data to establish current network needs in terms of facilities, hospitals and providers.
Provide initial feedback to managers and directors as to the probable and/or likely success or non-success of specific expansion attempts based upon analysis of geographical, financial and internal data.
Ensure that network adequately meets the needs of both internal and external customers in specialties represented, number of physicians/providers within each specialty, and distance of physicians/providers to members. Make independent decisions regarding the network need for additional specialty types and/or number of providers within assigned network via internal feedback, geographical data and internal reporting mechanisms as available.
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.
Responsible for the contracting of new, individual providers/physicians which includes the possible negotiation of language and terms as well as rates.
Responsible for the recruitment, contracting and maintenance (or overseeing the maintenance) of large medical groups.
Responsible for all re-contracting efforts of providers/physicians in assigned network to include, but not limited to, contract language changes via amendments, rate negotiations/changes, or entirely new contracts.
Provide initial orientations to new providers/physicians and their staff within assigned network(s) 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).
Initiate and coordinate written communication to providers/physicians via correspondence and newsletters in order to update physicians/providers regarding any major changes within the Plan and to ensure continued compliance with the Plan's policies and procedures.
Responsible for alerting management to trends in utilization of providers that could adversely affect the financial status of the organization and provide recommendations to management.
Assist in controlling provider costs through the reporting of possible provider fraud and/or abuse, establishing trends in provider utilization, and/or determining alternative avenues for provider services.
Responsible for the oversight of non-medical claims appeals from assigned in-network providers. Provide direct recommendations to Director of Operations as to whether a reimbursement determination should be upheld or overturned based upon knowledge of provider's claims history and trends.
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.
Provide market intelligence regarding competition and providers by remaining actively involved in the provider community.
Assist Manager of Network Provider Relations with URAC (accrediting body) requirements and interpretation, departmental compliance with Department of Defense rules and regulations, and the compilation and completion of the Department of Defense contract as it relates to Network Management.
Responsible for ensuring provider compliance with rules and regulations as dictated by legal, the Department of Defense, URAC, and departmental policies and procedures.
Assist Network Provider Manager through attendance of assigned meetings and participation on special projects. Assume role of manager on special departmental projects by directly coordinating and overseeing projects. In addition, participate in major decision making for department.
Provide training for new Network Account Managers and assists with the training of other Network Management staff as needed or upon request.
Assist in the development of the Network Management Department through the development/enhancement and implementation of new departmental process, policies and/or procedures. Ensure departmental compliance of established processes, policies and/or procedures through monitoring and providing feedback to both staff and manager.
Attend meetings for Plan as needed or required. Establish and coordinate routine in-services and individual meetings with providers within assigned networks, or other networks, as assigned. Oversee and assist. Provider Relations staff with the development of meeting materials and the coordination of large in-service events to ensure information is accurately reflected in the department's materials and presentations.
Ensure provider information is accurately reflected within Plan's internal systems as well as in communication tools (i.e., provider rosters, contract logs, etc.).
Effectively determine/communicate/resolve provider and office staff concerns.