Provider Relations Representative

A local healthcare company is looking for a strong Provider Relations Representative to support pediatric practices in the Atlanta area. We are a locally remote company that meets in person a couple of time a month, rest of the time you will work remotely. You must be within driving distance to Atlanta.

ESSENTIAL FUNCTIONS

Provide Pediatric Practice and Administrator support by serving as the primary internal and external point of contact and subject matter expert on provider and practice issues.

· Coordinate with internal operations and network staff to identify and report, track and communicate issues and resolutions.

Provider Relations:

• Possess a strong understanding of provider relations and practice management.
• Serve as the main contact for member practices, addressing their needs and concerns.

· Assist network practices with claim issues and inquiries, services issues, and practice compliance monitoring.

· Assist with the onboarding process for new practices, ensuring a smooth transition into the network.

• Collaborate with network staff to identify practice concerns, track issues, and communicate resolutions effectively.

Payor and Managed Care Relations:

· Serve as lead representative for assigned payor contracts, managing issue escalation, reporting, meetings, and communication.

• Nurture relationships with commercial payors and managed care organizations.

· Maintain accurate and up-to-date documentation of issue logs and follow-up actions in designated tracking tools.

• Preferred knowledge of CPT and ICD-10 coding.

Credentialing:

· Oversee day-to-day operational credentialing and affiliation activities for network providers, while ensuring credentialing processes follow professional standards, bylaws, state and federal regulatory requirements and maintain working knowledge of the statutes and laws.

· Lead the Credentialing Committee each month by reviewing files for initial and recredentialing, facilitating monthly meetings, preparing minutes, provider set-up and the credentialing database.

· Track expiration dates of license, DEA, COI and APP certifications of providers.

· Monitor NPBD, CMS Opt-Out report, OIG Exclusions, and GA Composite Board Sanctions.

· Complete delegated credentialing payor audits, report requirements, and oversee any corrective actions plans that result from the audits.

· Primary contact with payors on provider rosters, including submitting monthly rosters, confirming rosters are loaded accurately and tracked for practice reporting.

Engagement and Compliance:

· Work closely with Manager of Provider Relations to improve provider relations efficiency and effectiveness; and champion creative and innovative ways to engage providers.

Quality and Education Compliance:

• Conduct outreach and educate practices on quality programming, data transfer, minimum standards, and other quality initiatives.
• Analyze quality metrics to identify providers needing training and documentation/coding resources.
• Work with other departments to improve HEDIS quality metrics and help practices develop comprehensive, provider-specific plans to enhance their quality performance.

Payor Fee Schedules:

· Request, obtain, track, and validate internal rate calculations of payor fee schedules.

· Update fee schedule tracker in Teams for each Payor/Fee Schedule.

· Assist with collecting and documenting fee schedules for new or changed code sets.

Dues Management:

· Support activities related to dues, dues preparation and stocks.

Specialty Provider Relations, 3rd next reporting.

MINIMUM REQUIREMENTS

Associates and three to five years billing and claims experience and one-year credentialing experience preferred, or the equivalent combination of education and experience is necessary. Bachelor degree is preferred but not required.

Proficiency in Microsoft Word, Excel, and Power Point.

Strong interpersonal and listening skills using tact and diplomacy to interact and collaborate with management, external contacts, practices, providers, and all levels of staff. Excellent customer service skills are required.

Intermediate conceptual and analytical skills to analyze complex, unstructured problems and propose alternative solutions.

Ability to understand, interpret and communicate all types of provider and regulatory contracts.

Ability to multi-task in a fast-paced environment, exercise independent judgement, and track and follow-through on all tasks.

Pay: $55,000.00 - $70,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Flexible schedule
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: Hybrid remote in Brookhaven, GA 30329

Salary : $55,000 - $70,000