Provider Relations Consultant
Location: (Boston/Eastern MA)
Must have valid driver’s license and access to a car- travel 50% of time
Telecommute on days when not working in field
$65k - $75k + Outstanding Benefits
$5000 Sign on Bonus

Acts as the primary liaison between Provider Relations Consultants and internal Plan departments such as Claims, Benefits, Audit, Member and Provider Enrollment and Clinical Services to effectively identify and resolve claim issues. Works closely with the leadership team to identify issues and report trends.

Job Duties:

• Investigate, document, track, and assist with claims resolution.
• Interact with various operational departments to assure accurate and timely payment of claims in accordance with the plan's policies and procedures.
• Identify system changes impacting claims processing and work internally on resolution.
• Identify systematic issues and trends and research for potential configuration related work.
• Analyze trends in claims processing and assist in identifying and quantifying issues.
• Run claim reports regularly to support external provider visits.
• Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach.
• Act as liaison for all reimbursement, issues with providers. Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary.
• As needed, provides general education and support on Plan products, policies, procedures and operational issues.
• Manages flow of information to and from internal departments to ensure communication regarding Plans changes and updates.
• May outreach to providers according to Plan initiatives.
• Facilitates problem resolution. Initiates Plan interdepartmental collaboration to resolve complex provider issues.
• Identifies system updates needed and completes research related to provider data in Onyx and Facets.
• Processes reports as needed to support provider education, servicing, credentialing and recruitment.
• Ensures quality and compliance with State Agencies and NCQA.
• Other responsibilities as assigned.
• Understanding and implementation of Plan polices & procedures.
• Regular and reliable attendance is an essential function of the position.

Requirements:

• Bachelor's degree required
• 2 or more years of progressively responsible experience in a managed care or healthcare environmnet
• Experience with medicare and medicaid reimbursement methodologies
• Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms