SSM Health WellFirst Health Plan, Provider Network Specialist Senior in Saint Louis, Missouri
Assist providers in resolving reimbursement/payment issues based upon contract terms and ensure transition of related needed actions to the Customer Service, Claims or Benefits and Provider Pricing or Utilization/Case Management teams, as needed. Research and complete all provider appeals within timeframe required.
Provides subject matter expertise on internal resolution of complex operations and claims process issues that affect Providers. Researches underlying problems and represents provider community on problem resolution teams.
Initiate and lead the development of new Dean Health Plan (DHP) and Dean Export Network Expansions.
Provides training for Provider Relations new employees. Conducts audits for training purposes.
Monitors the inpatient claims review services (ICRS) delivered by the integrated wellness and disease management program. Reports and assists with one-on-one issues presented by providers or ICRS.
Conducts ongoing review of directory/website of additions/changes/terminations of providers so that timely updates are made to ensure data integrity. Support departmental leadership with the design, development, and implementation of provider network and communication strategies.
Participate in quality review meetings and act as a liaison with providers who participate in DHP’s provider quality, patient satisfaction and efficiency of care programs and activities. Assist in provider incentive program initial contract orientation and ongoing education.
Ensures DHP’s administrative processes are followed relative to the on-boarding of new providers, including making recommendations for provider status, provider system set-up and management of public facing provider data. Serve as a liaison between DHP’s provider community and internal departments in effectively identifying and resolving issues received from clinical, business office or pre-authorization staff. Facilitates and leads regularly-scheduled and ad hoc in-person, telephonic and on-line meetings and communication sessions with key providers. As needed, works directly with providers on regulatory compliance requirements established by the National Committee on Quality Assurance (NCQA), Quality Improvement Council (QIC), Office of the Commissioner of Insurance (OCI), etc.
Meet with territory providers regularly and proactively identifies education and performance improvement opportunities through these interactions and/or feedback from other DHP departmental staff, e.g. Utilization Management. Plans, organizes and conducts educational training seminars for the assigned provider network. Seeks out provider intelligence to support company initiatives and implementation strategies.
Identify contract requirements related to changes in status and subsequently generate new contract, amendment and termination requests, and record in the Network Provider Relations database.
Perform other duties as assigned.
- Bachelor’s degree, or equivalent years of experience and education
- Five years’ experience in health insurance or managed care HMO/PPO/self-insured product lines
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
Frequent keyboard use/data entry.
Occasional bending, stooping, kneeling, squatting, twisting and gripping.
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
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