Job Opportunity
Job ID:45888 Positions Location: East Lansing, MI Job Description General Purpose of Job: To
Description:
Positions Location: East Lansing, MI Job Description
General Purpose of Job: To ensure in network and participating providers are educated about Physicians Health Plan, including all associated products and affiliations and are satisfied with the relationship. Portfolio of physicians will represent high volume, high visibility physicians, ancillary and facility providers. Essential Duties: This job description is intended to cover the minimum essential duties assigned on a regular basis. Associates may be asked to perform additional duties as assigned by their leader. Leadership has the right to alter or modify the duties of the position.
- Manages relationships with participating and in network providers.
- Acts as a liaison between the Health Plan and Provider Network
- Creates and maintains strong working relationships and monitors ongoing activities with network providers.
- Identifies provider education opportunities and delivers appropriate training; coordinates, creates and disseminates provider-training materials, including but not limited to PHP policy and procedures, claim submissions, web based tools, coding resources, etc.
- Act as an agent for education of complex reimbursement policies and related issues.
- Assists in the investigation of suspected incidents of provider fraud and abuse.
- Assists as needed in the credentialing process; i.e. distributes applications, reviews process with physicians/facilities.
- Researches provider appeals and member grievances and makes recommendations for resolution.
- Works with appropriate staff to ensure that the provider directory/website accurately reflects information about the network.
- Prepares and facilitates operational meetings/seminars with the providers.
- Works with department management to assist in the recruitment of new providers to fill in identified network gaps.
- Monitors and assists with the activities related to the contract load process, EDI and other provider service issues.
- Assists providers in the investigation and resolution of claims issues.
- Facilitates/participates in creation of newsletter articles, billing guidelines and provider manual.
- Conducts routine educational sessions with network providers, office staff and billing services as appropriate.
Job Requirements
| General Requirements |
CPC or CPC-H coder preferred |
| Work Experience |
Minimum of three years in a network management related role, such as contracting, provider services, purchasing, etc. Experience in healthcare/managed care preferred. |
| Education |
Associates degree in business, health care management or related field, or high school diploma and minimum 2 years experience in managed care. Bachelors degree in business or managed care preferred. |
| Specialized Knowledge and Skills |
Strong negotiation skills; the ability to gain acceptance from others of a plan or idea and achieve a mutually beneficial outcome. Ability and willingness to calmly and effectively resolve escalated complaints and problems. Ability to gather, interpret and communicate policy statements. Excellent verbal and written communication skills; ability to speak clearly and concisely, conveying complex or technical information in a manner that others can understand, as well as ability to understand and interpret complex information from others including but not limited reimbursement policies standards. Ability to multi-task, shifting back and forth effectively between two or more activities or sources of information. Possesses good interpersonal skills, establishing rapport and working well with others. Ability to handle confidential information in a professional and sensitive manner. In-depth knowledge of Medicare reimbursement methodologies (i.e. Resource Based Relative Value System). Knowledge of claims processing systems and guidelines. |
University of Michigan Health Plan is committed to building and sustaining a diverse workforce that is reflective of the communities that we serve. University of Michigan Health Plan is an Equal Opportunity/Affirmative Action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected Veteran status.
Job Family
Administrative/Clerical
Requirements:
| Shift |
Days |
| Degree Type / Education Level |
High School / GED |
| Status |
Full-time |
| Facility |
Physicians Health Plan |
| Experience Level |
Under 4 Years |
|
Sparrow Health System
Oct 29, 2024