Provider Relations Rep II

Provider Relations Rep II

Job ID 2013-22338 # Positions 3
Location US-NY-New York
Search Category Customer Service
Type Regular Full-Time (30+ hours) Posted Date 3/21/2013
Additional Locations ..

More information about this job:
Summary:

Serves as liaison to providers (including physicians, hospitals, and/or ancillary providers) and internal departments at the health plan. Responsible for performing activities designed to establish and maintain positive and productive relationships with AMERIGROUP network providers for Medicaid and Medicare products. These activities include responding to inquiries from providers regarding benefits, claim resolution, appeal status, and authorization or referral information. Also may be responsible for recruiting providers to ensure network access and service adequacy. Provides training, guidance and assistance to Provider Relations Representatives I to support their skill development and successful completion of assignments. May perform position requirements in the field or telephonically, as appropriate. More emphasis is placed on field work at the rep level II.

Responsibilities:

1. Track and respond to in-person, telephonic, and written inquiries from providers and document all contacts in appropriate system per Plan (ie Sales force).

2. Ensures that provider relationships with the Plan are positive and productive for both parties.

3. Works with Providers to understand issues/concerns. Identifies root cause of problems and trends and participates in developing solutions. Works with Provider's staff and AMERIGROUP staff (local and/or corporate) to resolve the issue and monitor recurrence.

4. Assists with training and mentoring of the Provider Relations Representatives as needed to ensure departmental success and effective team work. In the absence of management, acts as the lead or senior associate in the department or for the assigned team.

5. Collaborates with local and corporate staff as necessary to ensure that appropriate applications are processed, contracts are executed and all providers are credentialed in a timely manner.

6. Analyzes provider network for adequacy in addressing members' medical needs and assists in the identification and recruitment of key providers where network gaps or needs exist.

7. Creates and maintains information required to support the network development process.

8. Develops training materials and conducts on-site provider education, orientations, and provider servicing visits to ensure providers are well-acquainted with AMERIGROUP benefits, policies, and procedures.

Provides expertise and assistance relative to provider billing and payment guidelines consistent with AMERIGROUP policies and procedures.

9. Provides follow up and intervention relating to provider complaints, thereby ensuring that the complaint process is appropriately handled within established time frames.

10. Participates in standing meetings, as necessary, regarding provider reimbursement issues and network development activities.

11. Performs other duties and special projects as assigned.

Qualifications:

EDUCATION AND EXPERIENCE

Education

Required:
- BA/BS degree or equivalent experience.

Years and Type of Experience Required:

Required:
- 5+ years of managed care experience, preferably in a Medicaid environment.

Specific Technical Skills

Required:
- Proficiency with Microsoft computer applications including Outlook, Word, and Excel.
- Claims experience/knowledge of medical coding
- Strong telephonic and customer service skills.
- Effective presentation skills.

Preferred:
- Experience using Sales force CRM.
- Experience using Facets.

Certifications or Licensures

Required:
- Valid Driver's License

Other:

Required:
- Excellent verbal and written communication skills.
- Detail-oriented.
- Ability to handle multiple tasks in a fast-paced environment.
- Must be service oriented and able to identify and resolve problems.
- Appreciation of cultural diversity and sensitivity toward target population.

PHYSICAL REQUIREMENTS
- Must be able to operate a computer, telephone and fax machine.
- Must be able to travel locally.
- Must be able to operate a motor vehicle.
- Must be able to conduct and participate in meetings.

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