Description: Job Summary:
In addition to the responsibilities listed below, this position is also responsible for aiding the planning and development of provider satisfaction strategies to improve network relationships and enhance provider engagement; supporting the development of provider relations programs to facilitate effective provider communications and problem resolution; and creating and distributing standard media materials (e.g., articles and newsletters) and publications to providers independently; ensuring providers adhere to regulatory and contractual requirements; escalating standard and nonstandard compliance issues to appropriate parties; gathering materials to support organizational responses to regulatory audits; and beginning to deliver provider education and/or onboarding.
Essential Responsibilities:
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.Supports continuous improvement efforts by: organizing provider, claims, and contracting data to assist the team in identifying and/or consulting on continuous improvement opportunities across the contract ecosystem (e.g., identifying business and operational disparities between organizational and provider expectations, constraints, and risks to accessible care, building and maintaining relationships); engaging in the implementation of process improvement initiatives to aid providers and business goals;  and may also include supporting standard and non-standard analyses of provider and market data to develop recommendations for improvement initiatives.Ensures contract commitments are met by: organizing provider data in appropriate data platforms and supporting the consultation of provider compliance; documenting provider activities and/or supporting the collaboration with alternate stakeholders to ensure compliance with contract terms and conditions; and following guidelines to ensure provider compliance with state and federal regulations as well as KP policies and procedures.Supports contract strategy development by: executing tasks to support strategies that improve access to patient care while managing outside service costs, with minimal supervision; collaborating with team members to provide consultation on local service delivery planning to aid in the achievement of provider priorities and strategies; engaging in collaborative cross-functional workgroups and/or executing on strategies to meet the unique needs of diverse stakeholders; and participating in and/or beginning to conduct peer training for new hires and contingent workers (e.g., establishing contract language, determining payment rate parameters, defining workflow and business processes, and ensuring cross-training across all service lines).Supports the growth of the Provider Network by: researching and evaluating potential partners/alliances for assigned service area to fill service gaps or decrease costs in current service offerings; developing trusting relationships with providers to understand their role in the external network; serving as a liaison between providers and KP by completing communication tasks independently (e.g., contract compliance such as access, availability, referral operations, and/or supporting member complaints); and supporting provider site visits, daily interactions, and ad hoc meetings by organizing components of itineraries and agendas, gathering credentialing materials, and/or supporting the initiation of this process.Contributes to provider satisfaction by: using comprehensive foundational knowledge of provider/contract operations to consult on issues that arise from contract configuration/interpretation and/or related to claims/disputes, billing, payment, reimbursement, other operational issues, and/or directories; contributing to tasks to ensure requests for information, questions, and problems are identified, documented, and addressed in a timely manner; and creating training materials to aid provider education and orientation on health plan systems, processes, and/or credentialing. Minimum Qualifications:
High School Diploma or GED AND five (5) years of experience in health care delivery or operations in a managed care environment, customer relationship management, or a directly related field.
Additional Requirements:
Knowledge, Skills, and Abilities (KSAs): Written Communication; Compliance Management; Interpersonal Skills; Time Management; Quality Assurance Process; Computer Literacy; Trend Analysis; Business Relationship Management; Presentation Skills; Health Care Reimbursement Preferred Qualifications:One (1) year of experience working with Microsoft Excel, including working with formulas and developing integrated workbooks.Two (2) years of experience with industry standard claims coding and submission processes.