Under general supervision of the Provider Network Supervisor, the Network Representative I (Network Representative) is responsible for the network provider functions to include, network provider orientation, education, and coordination and reimbursement issue resolution.
• Coordinate resolution with provider for specific issues related to claims, eligibility and referrals
• Schedule and complete annual in-person provider in-service or site visit
• Within 60 days of contract execution, schedule and complete orientation training with prepared materials – develop and maintain orientation materials
• Maintain open communication with providers and troubleshoot issues related to credentialing, provider rosters, provider location information, reimbursement processes including provider access to FTP and TPA provider portal, adjudication rules, outstanding reimbursement items
• Assist as needed with provider credentialing efforts and with the maintenance of provider data for claim adjudication purposes by TPA.
• Maintain strong working relationships with network physicians and ancillary providers, and their office staff, to assure provider satisfaction through value-added services performed primarily through face-to-face or telephone interactions
• Maintain strong working relationships with outside vendors and, such as TPA and Credentialing ASO, as well as internal team members and partners.
• Collaborates with co-workers within the department and within the organization.
• Medical care delivery and local market dynamics
• MAP provider landscape
• Interpersonal skills and tracking of conflict resolution
• Planning and prevention of potential issues related to reimbursement
• Effective problem solving skills with follow through
• Strong listening, verbal, presentation and written communication skills
• Word, Excel, Power Point and use of the internet
• Interface effectively both externally and internally with a wide range of people including physicians, office staff and other health plan staff
• Work independently with minimal supervision
MINIMUM EDUCATION: Associates college degree in a relevant field
PREFERRED EDUCATION: Bachelor’s degree in a relevant field
MINIMUM EXPERIENCE: Minimum of 4 years of work experience in a related field.
PREFERRED EXPERIENCE: Medical office or health insurance customer service experience is preferred, and professional provider relations experience involving physicians and administrative staff is strongly preferred.