Network Service Consultant - Peak Health

This role is responsible for developing and maintaining collaborative relationships with providers (physician, hospital, ancillary, vendors, etc.) based on mutual respect, high-quality outcomes, and patient and provider satisfaction. The role shapes the network landscape by offering objective data and education to all stakeholders in the market and across all product lines. The incumbent will report to the Manager of Network Services and will be an integral, collaborative member of the Provider Relations team.

Qualifications

• Bachelor’s Degree in business or healthcare-related field (required)
• Master’s Degree in Healthcare Administration or Business Administration (preferred)
• Certified Medical Coder (CMC) through the American Academy of Professional Coders (AAPC) (preferred)
• Basic understanding of contracts, Value Based Reimbursement (VBR), performance-based provider reimbursement programs, and Commercial (fully insured and self-funded), Medicare Advantage, Medicaid, and PEIA products
• Understanding of regulatory reporting for provider networks (e.g., WV Department of Insurance, Department of Medicaid/Health Services, and CMS)
• Understanding of provider quality measurements and systems such as Medicare STARS, HEDIS, and PCMH quality programs

Responsibilities

• Uphold the health plan mission of making healthcare more accessible, understandable, and collaborative while interacting with providers and colleagues
• Educate providers regarding policies and procedures related to credentialing, contracting, authorizations, referrals, claims and/or encounters, grievances and appeals, health education, provider education, population health management, care management, pharmacy management, Electronic Health Records, medical record submissions, Health Information Exchange, data exchange, electronic Data Interface, and regulatory updates
• Build and maintain strong provider relationships
• Conduct routine periodic outreach to providers based on business plan and operational goals (e.g., email, telephone, in-person, and scheduled webinar meetings)
• Assess provider efficiencies when dealing with the health plan
• Conduct initial provider orientations and ongoing educational outreach
• Conduct group training sessions
• Assist with simple provider contract questions, research problems, and resolve escalated issues
• Represent the health plan at healthcare association functions (e.g., HFMA, MGMA, AMA)
• Participate in regulatory reporting for provider networks (e.g., WV Department of Insurance, Department of Medicaid/Health Services, and CMS)
• Stay abreast of competitors and regulations in the market
• Support strategic positioning in geographic areas to develop and maintain provider networks
• Assist the Credentialing Department with difficult-to-obtain documents
• Initiate and maintain effective communication channels with matrix partners (e.g., Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing, Member and Provider Service) to resolve issues and facilitate team and business priorities/opportunities

Skills

• Strategic thinking and attention to detail
• Knowledge of federal and state laws (e.g., CMS, BMS)
• Excellent written and oral communication
• Demonstrated ability to build and retain relationships
• Proficiency with Microsoft Office
• Experience with Commercial (self-funded and fully funded), Medicare, and Medicaid products
• Understanding of the provider credentialing and data management process
• Working knowledge of claims and/or coding
• Established provider relationships in West Virginia

Schedule

• Scheduled weekly hours: 40
• Exempt position
• Some travel may be required for offsite meetings

Work Environment

• Standard office environment