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- Promotes good provider relations by addressing operational issues and evaluate contract and credentialing compliance.
- Attends Joint Operating Committee meetings as assigned.
- Responsible for contracting with Hospital Based Physicians.
- Responsible for the Letter of Agreement Process.
- Tracks and maintains any CPI increase for contracted hospitals.
- Communicates with consultants to provide up-to-date information regarding TSPMG.
- Provides feedback to the appropriate management personnel when issues are identified relative to patient care, billing and authorization.
- Works closely with Department of Quality Risk Management, Business Office, Claims and Medical Audit to identify and resolve operational issues relating to contract development, administration, and to facilitate quality of service and reimbursement.
- Responsible for implementation of newly developed contracts by providing on site training and orientation to the community providers office staff.
- Provides support to the Contract Manager in regards to capitation arrangements with Core Consultants.
- Responsible for the analysis and evaluation of metrics to evaluate key business indicators including timeliness and accuracy of contract configuration. Contributes to metrics and analyses for the purposes of vendor oversight, network adequacy (accessibility & capacity), member satisfaction, vendor integrity, business continuity, product recall, etc. and determining appropriate next steps. Oversees development of vendors corrective action plans and ensures submitted plans meet quality and business process standards. Accountable for ensuring vendors/suppliers are responsive to quality and service level concerns and influencing stakeholders to ensure that interventions are timely and effective.
- Responsible for development and maintenance of positive ongoing relationships with community providers. Serves as the key contact for community providers in resolving escalated complex claims concerns and achieving provider satisfaction. This position is also responsible for the regular monitoring, collection, and reporting of performance metrics, territory profile reporting of field operations activities, and the coordination of Kaiser Permanente Payor/Provider conference activities.
- Minimum two (2) years of experience in a field position doing provider relations.
- Minimum two (2) years of experience in a field position.
- Minimum two (2) years of public speaking and presentation skills.
- Minimum two (2) years of provider contracting experience.
- Experience in billing department protocol and procedures.
- Bachelors degree required, OR four (4) years of experience in a directly related field.
- High School Diploma or General Education Development (GED) required.
- High ethical standards.
- Proficient in Excel and Word.
- Thorough knowledge and understanding of provider relations, physician reimbursement and managed care contracts.
- Knowledge of physician office operations (example::CPT-4 codes, ICD-9 codes, capitation etc.).
- Minimum five (5) years of experience in Health Care Administration, Managed Care Contracting or Health Care finance is preferred.
- Knowledge of Medicare, Medicaid, regulatory requirements and practice protocols.
- Knowledge of quality assurance and utilization management concepts.
- Knowledge of KFHP contracting process, benefits coverage, QA goals and objectives, medical referrals processing procedures.
- Bachelors degree in nursing.