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Provider Relations Coordinator

Company: North East Medical Service
Location: Daly City
Posted on: June 6, 2021

Job Description:

The Provider Relations Coordinator (PRC) is responsible for a wide range of communication activities to support, develop and maintain service relationships with all participants (physicians, hospitals and health systems, providers and administrators) of the MSO provider network. Primary focus will be on timely completion of provider credentialing and re-credentialing activities according to NCQA requirement for over 1,000 network providers. This position serves as a liaison between NEMS organization and MSO network providers and other community partners; responds to direct inquires about policies, contracts, rates, changes, referrals, credentialing, provider appeals and member grievances, etc.; provides managed care training, educations and guidance and to manage provider/client communication efforts. The PRC acts as the face of the pro contact of NEMS to the community for the overall medical management communications and plans.

ESSENTIAL JOB FUNCTIONS:

  • Serve as liaison between NEMS organization and MSO network providers and other community partners; develop and send

provider communications, maintain provider on-line tools/resources.

  • Assist in the development of provider orientation and education materials to contracted provider entities and business associates

for the Medicare and Medi-Cal manage care program.

  • Assist with the development of written communications for general NEMS MSO update notifications, provider newsletter, MSO

website, and maintaining provider on-line tools/resources.

  • Responsible for the initial credentialing and re-credentialing verification activities for new and recertified providers, include

licensure verification, follow up on completion of applications and/or missing data clarification follow NCQA requirement.

  • Responsible for creating and maintaining a master listing for credentialed physicians; produce periodic reports to track for

physicians' re-credential status, quality assurance information, verification of sanctions, and incidents investigations status.

  • Coordinate and facilitate the NEMS/MSO Credentialing/Privileging Committee meeting and follow up on action requests by the

Committee.

  • Be point of contact for credentialing or privileging denials, provider complaints and/or appeals about credentialing.
  • Coordinate with contracted entities for Credentialing sub-delegation audit activities.
  • Coordinate with contracted Health Plan(s) for annual delegation audits, and any other audits conducted by DHCS/DMHC/CMS

as applicable.

  • Communicate with contracted Health Plans to report new, updated, or terminated physician and practice information as required

per SB137.

  • Responsible for the timely production of New Member Welcome Packet to managed care members become eligible with NEMS

within 30 days of enrollment, to meet timely completion requirement for IHA/HRA per CMS and/or DHCS standard.

  • Research and understand complex authorizations, claims, provider appeals, benefit coverage issues raised by physician

practices, members, and/or health plan partners, coordinate follow up activities for resolution.

  • Identify and research a variety of issues related to provider contracting, compliance, and operational issue utilizing various

sources, including but not limited to current contracts, publications, websites, and provider notifications.

  • Submit communication materials to providers and clients outside of NEMS organization to department supervisor and/or

manager for review and approval.

  • Perform other duties as assigned.

QUALIFICATIONS:

  • BA/BS Degree in Social Sciences, Business or General Education with 2-3 years' experience working in managed healthcare

setting in the areas of provider relations, claims, or utilization management, or equivalent combination of education and

experience.

  • Associate Degree may be considered with relevant, equivalent work experience.
  • Knowledge of Medicare and/or Medi-Cal managed care program and/or other state-sponsored program a plus.
  • Prior managed care experience with knowledge of CMS/DHCS health policy a plus.
  • Superior ability to communicate (spoken and written) effectively with a variety of professionals, including physicians and other

healthcare providers, business administrators and contracting managers, billing and revenue cycle agencies.

  • Must be PC literate - Strong Excel, Word, Power point, and Outlook skills;
  • Knowledge of community resources and cultural a plus.
  • Detail-oriented and organized with the ability to interpret DHCS policy letters and make decisions.
  • Good organization and problem-solving skills.
  • Ability to self-manage and work with multiple departments within the organization and external clients.

LANGUAGE:

  • Must be able to fluently speak, read and write English.
  • Fluent in other languages are an asset.

STATUS:

  • This is an FLSA NON-exempt position.
  • This is not an OSHA high-risk position.

NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).

Keywords: North East Medical Service, Daly City , Provider Relations Coordinator, Other , Daly City, California

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