Internal Provider Relations Consultant
Vir Healthway, Boston, MA, United States
Internal Provider Relations Consultant
Boston, MA 02108
Must-Haves BA/BS required or related field, or an equivalent combination of education, training and experience 2 or more years of progressively responsible experience in a managed care or healthcare environment Must have valid driver's license and access to reliable transportation Experience with Medicare and Medicaid Reimbursement Methodologies. Understanding of provider coding and billing practices. Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms. Job Description
Acts as the primary liaison between Provider Relations Consultants and internal Plan departments such as Claims, Benefits, Audit, Member and Provider Enrollment, Credentialing, and Clinical Services to effectively identify and resolve claims and other provider concerns. Works closely with the leadership team to identify issues and report trends.
Investigate, document, track, and assist with claims resolution and other provider concerns Interact with various operational departments to assure accurate and timely payment of claims in accordance with the plan's policies and procedures Identify system changes impacting claims processing and work internally on resolution Identify systematic issues and trends and research for potential configuration related work Analyze trends in claims processing and assist in identifying and quantifying issues Run claim reports regularly, in tandem with the Provider Relations Consultants, to support external provider visits Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach Act as liaison for reimbursement and set-up issues with providers. Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary As needed, provides general education and support on BMCHP products, policies, procedures and operational issues Educates providers on the Electronic Billing (EDI) and Electronic Funds Transfer capabilities Manages flow of information to and from internal departments to ensure communication regarding Plans changes and updates May outreach to providers according to Plan initiatives in an effort to assist the team Facilitates problem resolution. Initiates Plan interdepartmental collaboration to resolve complex provider issues Identifies system updates needed and completes research related to provider data in Onyx and Facets Processes reports as needed to support provider education, servicing, credentialing and recruitment Ensures quality and compliance with State Agencies and NCQA Other responsibilities as assigned Understanding and implementation of Plan polices & procedures Regular and reliable attendance is an essential function of the position
Boston, MA 02108
Must-Haves BA/BS required or related field, or an equivalent combination of education, training and experience 2 or more years of progressively responsible experience in a managed care or healthcare environment Must have valid driver's license and access to reliable transportation Experience with Medicare and Medicaid Reimbursement Methodologies. Understanding of provider coding and billing practices. Experience with ICD-10, CPT/HCPCS Codes, and billing claim forms. Job Description
Acts as the primary liaison between Provider Relations Consultants and internal Plan departments such as Claims, Benefits, Audit, Member and Provider Enrollment, Credentialing, and Clinical Services to effectively identify and resolve claims and other provider concerns. Works closely with the leadership team to identify issues and report trends.
Investigate, document, track, and assist with claims resolution and other provider concerns Interact with various operational departments to assure accurate and timely payment of claims in accordance with the plan's policies and procedures Identify system changes impacting claims processing and work internally on resolution Identify systematic issues and trends and research for potential configuration related work Analyze trends in claims processing and assist in identifying and quantifying issues Run claim reports regularly, in tandem with the Provider Relations Consultants, to support external provider visits Develop and enhance our physician, clinician, community health center and hospital relationships through effective business interactions and outreach Act as liaison for reimbursement and set-up issues with providers. Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary As needed, provides general education and support on BMCHP products, policies, procedures and operational issues Educates providers on the Electronic Billing (EDI) and Electronic Funds Transfer capabilities Manages flow of information to and from internal departments to ensure communication regarding Plans changes and updates May outreach to providers according to Plan initiatives in an effort to assist the team Facilitates problem resolution. Initiates Plan interdepartmental collaboration to resolve complex provider issues Identifies system updates needed and completes research related to provider data in Onyx and Facets Processes reports as needed to support provider education, servicing, credentialing and recruitment Ensures quality and compliance with State Agencies and NCQA Other responsibilities as assigned Understanding and implementation of Plan polices & procedures Regular and reliable attendance is an essential function of the position