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
- Assist in the development of provider orientation and education
materials to contracted provider entities and business
for the Medicare and Medi-Cal manage care program.
- Assist with the development of written communications for
general NEMS MSO update notifications, provider newsletter,
website, and maintaining provider on-line tools/resources.
- Responsible for the initial credentialing and re-credentialing
verification activities for new and recertified providers,
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
- 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
- Communicate with contracted Health Plans to report new,
updated, or terminated physician and practice information as
- 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
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.
- 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
- Associate Degree may be considered with relevant, equivalent
- 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
healthcare providers, business administrators and contracting
managers, billing and revenue cycle agencies.
- Must be PC literate - Strong Excel, Word, Power point, and
- 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.
- Must be able to fluently speak, read and write English.
- Fluent in other languages are an asset.
- 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).