Out of Network Coordinator (Remote/Hybrid Option), NC

Competitive Compensation & Benefits Package!

Position eligible for –

• Annual incentive bonus plan
• 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.

Office Location: Remote/Hybrid option in NC; Available for any of Partners' NC locations

Projected Hiring Range: Depending on Experience

Closing Date: Open Until Filled

Primary Purpose of Position: The Out of Network Coordinator will assist in the credentialing, development and management of the provider network for consumers who have been identified as having mental health, substance abuse or intellectual development disability needs.

Role And Responsibilities

An Out of Network Coordinator’s primary duties may be one or more of the following:

• Obtains and maintains information regarding Out of Network (OON)/Member Specific Agreements (MSA);
• Is responsible for ensuring that all OON/MSA providers are offered the opportunity to join the network;
• Serves as the LME/MCO liaison to providers with an OON or MSA providing technical assistance and training needed to assist providers in understanding Partners processes, policies and procedures as it relates to their limited enrollment, authorization, billing, contracting and connectivity requirements;
• Is responsible for the Out of Network Agreements (OON) and Member Specific Agreements (MSA) including collecting application information and ensuring the processing of those application through contract completion;
• Assists with development and implementation of contracts for agencies and licensed independent practitioners based on network adequacy needs;
• Visits provider agencies to facilitate communication & collaboration;
• Completes routine and ongoing contract compliance monitoring to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations;
• Coordinates/collaborates to schedule, prepare for and conduct on-site monitoring/audits;
• Interprets audit results, identifies trends/patterns that impact service/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree of quality;
• Participates on the Network Development Cross-Functional Team (NDCFT);
• Chairs sub-committees and/or collaborative efforts related to the NDCFT as needed and when appropriate;
• Participates in the development of performance measures for each contracted provider;
• Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the Consumer Services Department, the Program Integrity Department, the Quality of Care Committee, Network Management Committee or as indicated by another agency or departmental identified need;
• Serves as a resource to other departments within the LME/MCO on OON/MSA provider-related issues;
• Serves as a liaison with other departments within the LME/MCO and with various NC DHHS Departments, per rule requirements, to coordinate Specialist’s activities and findings.
• Works closely with IDD and MH/SA Care Coordination, UM, Customer Service and the Contracts Department in collecting documentation required to issue an OON or MSA;
• Participates in Provider Forums as requested and provide technical support and assistance to Provider Councils as needed;
• Interprets and assists in developing and maintaining policies and procedures.
  
  

Knowledge, Skills And Abilities

• Considerable knowledge of the laws, regulations and policies that govern the program
• 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: Associate’s Degree and two (2) years of case management, credentialing, provider enrollment, auditing or monitoring experience in MH/SU/I-DD or an equivalent combination of education and experience. Must have ability to travel as needed to perform job duties.