Provider Services Specialist

This position assists with their tracking and timely resolution. This liaison position is responsible for timely and accurate investigation of provider requests and/or concerns including, but not limited to benefit-setup, fee schedule setup, claims processing or level of service from the health plan.

The incumbent is also responsible in establishing and maintaining educational material/presentations in an effort to manage the ongoing education of the providers and their staff regarding Hometown Health's policies and procedures.

This position is challenged to keep the Network Services Supervisor, the Provider Service Representative 2, and other appropriate staff informed of opinions, viewpoints, and perceptions of Hometown Health's provider community, while building and maintaining provider relationships.

The incumbent must be able to perform the following:

1. Develop and build provider relationships with strong customer service and support while adhering to Hometown Health and Renown Health policies and procedures.

2. Assist the Provider Services Representative II and Hometown Health leadership with the development and distribution of new and revised educational material, surveys, and additional correspondence to provider offices.

3. Maintain and update database of current contact information for contracted provider offices.

4. Monitor and manage Network Services email handles (Provider Relations and Provider Updates) and fax queue.

5. Collaborate across the organization to resolve identified provider concerns, education opportunities, and quality of care concerns to improve the member and provider experience.

6. Support Provider Services Representative II and Hometown Health leadership in identifying and resolving issues experienced by the provider community such as escalated claim issues through research, education, and process improvement opportunities.

7. Maintain and manage the content of the external Provider page on website including reviewing and updating the Administrative Guidelines and other provider facing content.

8. Completes provider additions, terminations, and demographic changes timely to ensure provider directory accuracy.

9. Engage in provider directory maintenance through audits and utilizing the Quest Analytics platform and data to ensure maintained compliance with state and federal regulations and accreditation standards.

10. Monitor Network Adequacy requirements through running and reviewing reports.

11. Supports Network Services leadership with other duties as assigned to support team initiatives.

12. Operational knowledge of the provider portal EpicCare Link and Epic Tapestry.

13. Excellent verbal and written skills, including the ability to draft internal and external correspondence.

14. Strong organizational skills to maintain efficiency in a busy environment.

15. Working knowledge of the health insurance industry, medical coding, and familiarity with state and federal regulations as well as NCQA and URAC accreditation standards

This position does not provide patient care.

The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Education:

Must have working-level knowledge of the English language, including reading, writing, and speaking English.

Experience:

Two-year college degree from an accredited college. This requirement can be substituted by two years of healthcare provider office or group health insurance experience.

License(s):

None

Certification(s):

None

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.