Job Description

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Provider Network Acct Specialist-Physical Health (Remote Opt)-NC

Full Time Social Services Albemarle, NC, US 1 Attachments

4 days ago Requisition ID: 2291

Competitive Compensation & Benefits Package!

• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details.

Location: Remote option; Available for any of Partners' NC locations

Projected Hiring Range: Depending on Experience

Primary Purpose of Position: This position assists in the development, support, and management of the provider network for providers who deliver both physical health and behavioral health services. This Physical Health Provider Network Account Specialist is responsible for developing, maintaining and servicing a high quality, marketable and satisfied provider network for Partners Health Management. This position is expected to build and sustain strong working relationships with cross functional departments, physical health plan partners, both physical and behavioral health providers, and essential providers. The Physical Health Provider Network Account Specialist supports successful operations of primarily physical health providers but also providers who provide both physical and behavioral health services within our healthcare delivery model. They provide strategic education on the special needs of the enrollees, a comprehensive understanding of the contract, and serves as a liaison with other Partners health plan partners that the provider works with. The Physical Health Provider Account Specialist would carry a caseload of specialized providers that provide both BH and PH services, and multiple contracts, Essential Providers (LHDs, Rural Health, AMH+, Free Clinics, etc.), as well as provide customer service and mediation/liaison activities with Partners Physical Health to current Physical Health providers.

Role and Responsibilities:

• Account Specialist Roles and Responsibilities:
  • Educating the providers to ensure they understand the contract and the Medicaid initiatives regarding this population and the contract requirements
  • Communicates and collaborates to mitigate issues and risks around providers and Physical health vendors, EVV vendors, CVS/Caremark, NEMT, LTSS and others as assigned.
  • Educating the providers to the required and/or best practices for their provider type and the quality measures.
  • Coordinate with internal departments and/or the physical health plan partner to mediate and resolve provider questions or issues regarding prior authorizations, claims submission, EVV, LTSS, payment issues and other questions as needed.
  • Handles or facilitates appropriate scheduling, agenda, materials, location, of provider meetings as needed.
  • Collaborate with other departments and/or the physical health plan partner to ensure provider data is correct and includes any needed updates.
  • Assists providers to obtain and complete Provider Change Forms as needed. Provides information and participates in management meetings as requested.
  • Enhance account relationships by investigating, documenting, and resolving provider matters and effectively handling and responding to account changes and correspondence.
  • Provide information and status updates for providers regarding incentive agreements and how to maximize their performance.
  • Regularly meets with other internal departments and/or the physical health plan partner to create, revise and adjust strategy for assigned provider groups to meet overall performance goal.
  • Assists with development and implementation of contracts for agencies and licensed independent practitioners.
  • Reviews and Signs-off on Provider Invoices as assigned.
  • Chair, Co-Chair, and Participate in internal and external committees.
  • Capable of working with all levels of the organization including Executive Leadership Team, Departmental Directors, and Managers to assist with problem resolution.
  • Active Participation in other department subgroups/initiatives to further network development and adequacy.
  • Oversight of identified performance measures with providers.
  • Work with finance to track and monitor utilization of all funding mechanisms.
  • Technical Assistance-Assisting providers as needed with our internal systems-authorization, claims, alpha issues.
  • Provides support for specialized providers that provide both BH and PH services providers and assists with issues, concerns, and resolution to the provider.
  • Provides support for Essential Providers (LHDs, Rural Health, AMH+, Free Clinics, etc.)
  • Coordinate meetings with Providers and Internal staff when needed.
  • Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed.
  • Participate in internal workgroups and/or the physical health plan partners that involve existing providers.
  • Assist with Identifying & developing provider training to meet provider needs.
  • Assigned to physical health, EVV, LTSS initiatives, and other special provider populations as identified and indicated.
  • Development of Policy & Procedure, and notifications associated with Contract Performance monitoring.
  • Responsible for pulling multiple reports from ALPHA/Report Manager and/or other databases to share with providers for them to improve upon.
  • Provides Outreach to both behavioral health and physical health providers for any administrative issues or items related to contracting or service provision.
• Participation in internal and external committees, as assigned.

Knowledge, Skills and Abilities:

• Considerable knowledge of the laws, regulations and policies that govern the program
• General knowledge of Physical Health business practices, rules, and regulations
• Exceptional interpersonal and communication skills
• Strong problem solving, negotiation, arbitration, and conflict resolution skills
• Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint
• Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws, rules and regulations to various situations; to apply regulations and policies for maintenance of consumer medical records, personnel records, and facility licensure requirements
• Ability to make prompt independent decisions based upon relevant facts
• Ability to establish rapport and maintain effective working relationships
• Ability to act with tact and diplomacy in all situations
• Ability to maintain strict confidentiality in all areas of work

Education/Experience Required: Bachelor's degree in health care administration, business administration, accounting, finance, or human services, and five (5) years of experience in provider network management, health care insurance or other health care delivery setting. A combination of relevant experience may be considered in lieu of a bachelors degree. Must be able to travel as needed to perform job duties. NC residency is required.

Education/Experience Preferred: Master's degree in business administration or human services and two years experience in a physical health or clinical environment. Experience with Physical Health Services and business operations, Electronic Visit Verification, preferred but not required.

Licensure/Certification Requirements: None

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