Full-Time Provider Relations Specialist

• Works directly with providers to ensure they are serviced, maintained and educated on all policies and procedures in an efficient, positive and professional manner
• Collaborates with both internal and external stakeholders to meet existing and newly identified needs of the providers and their patients
• Maintains a comprehensive provider contact database comprised of multiple tracking reports
• Builds relationships with each of the Clinical Centers of Excellence (CCEs) to coordinate provider nomination requests and pursuit status, prescriber authorizations, and ongoing support for the members
• Assists with incoming inquiries through the dedicated Provider Enrollment mailbox and ServiceNow tickets escalated by the Call Center to address provider inquiries such as requests for Remittance Advice (RA) statements, claim denial reviews due to provider enrollment issues, etc.
• Works with appropriate stakeholders on timely resolution of provider grievances
• Supports the secure exchange and organized management of all provider enrollment documentation, including Terms & Conditions Agreements, EFT and W9 forms, and related documentation
• Assists with ensuring providers are compliant with all program requirements per the terms of their agreement regarding availability and access standards, evaluating compliance as required
• Provides education, coaching and guidance to providers on required metrics, programs and other quality initiatives
• Takes full ownership of a provider’s recruitment, enrollment and participation experience, including outreach, education, sending / receiving / processing agreements, liaising with the CCE as appropriate, and responding to claims status inquiries
• Ensures provider records are updated timely with requested changes to a provider’s demographic information, contract status, updates are sent for processing timely and ensures updates are performed accurately within the system
• Performs research and analysis on pended / escalated claims, working with appropriate departments and providers to find resolution

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