Position Summary:
The primary functions will be to serve as the interface among the physician network, the IPA, and contracted health plans through ongoing education, training, and support activities. This individual will establish and maintain relationships with practices, providers, and members through excellent customer service and rapport. Supporting, educating, and outreach to providers on initiatives such as encounter data submission, AV program and Clinical Initiatives to optimize practice performance is critical. This individual will collaborate with the Risk Adjustment and Quality, Credentialing, Information Systems, Clinical Services, Compliance, and Claims departments, as well as the marketing department, to facilitate growth. Must be bilingual in English and Vietnamese.
Principal Duties and Responsibilities:
- Provide support to providers with issues related to contracting, capitation, claims, referrals, and eligibility. Will act as a liaison between provider and applicable department.
- Serve as the primary point of contact and conduit between IPA and Physician’s DataTrust’s internal departments
- Establish and maintain provider rapport by conducting field visits to provider offices weekly
- Responsible for developing and strengthening relationships with various provider groups
- Responsible for the post-recruitment phase of the practice cycle to facilitate:
o Onboarding
o Training
o Payer contract offerings
o Strategic network communication
o Performance reports and scorecards
o Establish Cozeva and Aerial Care logins for providers and maintain records of logins provided
- Ensure the collection and proper distribution of contracting, credentialing, and updated information from participating practices/providers. Follow the process from end to end.
- Handle wrong lab claims for IPA including cap deduct warning letters and tracking
Facilitate contracting, including negotiation, drafting agreements, preparing Letters of Agreement and processing all agreements.
- Confidence in preparing and leading meetings as assigned
- Maintain PCP, Specialty and Ancillary rosters including health plan ID numbers *
- Timely review and response of health plan roster proofs*
- Coordinate with the Marketing department to develop, organize, and participate in marketing efforts to organically grow the IPA
- Identify and recruit new providers to add to the network to retain and reach new membership
- Process provider adds, changes and terminations using checklists to include configuration notification and health plan notification along with electronic file maintenance of contract. *
- Maintain provider manuals for PCP and Specialists including in-service materials.
- Provide oversight of practice contract implementation; identify opportunities for process improvement and facilitate issue resolution
- Guide members through challenges they may have with contracted groups and work to resolve network issues
- Perform other responsibilities as assigned for special projects and escalated issues
- Provider correspondence including newsletters, fax blasts and mass mailings. *
- Conduct and compile results for annual member, provider, and access surveys to be provided to QI nurse for presentation to the QI committee
- Complete audit tools for Health Plan audits upon request
- Assist with IPA meeting scheduling and preparation
Education and/or Experience:
- Bachelor’s degree in Business, Healthcare Administration or related field of study; or, an equivalent combination of education and/or experience
- Minimum 5 years of experience in the healthcare industry; preferably with healthcare network operations
- Demonstrated understanding of risk and value-based contracting
- Proficiency with Microsoft Office suite and Internet/Intranet resources
- Knowledge of Medicare regulations, NCQA, HIPAA compliance regulations
- Familiar with payment alternatives such as fee for service, capitation, and performance compensation.
- Familiar with patient and practice risk adjustment mechanics, HCC/RAF
- Experience with database management in a healthcare setting
