Provider Relations Representative
Nascentia Health, North Tonawanda, NY, United States
The Provider Relations Representative for the Western Region will cover the following counties: Allegany, Cattaraugus, Chautauqua, Genesee, Livingston, Orleans, and Wyoming.
Applicants who reside in Jamestown, Olean, Ellicottville, Dunkirk, Houghton, and surrounding cities are encouraged to apply.
Responsible for maintaining working relationships within all vendors, both out-of-network vendors and within the provider network, as well as community relations contacts. Maintain accurate and current provider databases relating to provider facilities and credentialing information. Perform audits of electronic provider files, credentialing, contracting materials and claims submissions to ensure all contracted providers follow policies and procedures.
Performance Responsibilities and Standards
Assists in the day-to-day operations of the Provider Relations department.
Research, contacts, and works to secure agreements with vendors who provide covered services in compliance with plan requirements. Obtains new service provider application and all necessary credentialing, and forwards to Provider Relations Credentialing & Contract Management Specialists to be processed.
Prepares contracts and addendums to be executed between plan and providers.
Resolves all concerns raised by providers and provides up-to-date information on all new and existing policies and procedures.
Directs vendors to the correct contact persons at Nascentia and assists with addressing outstanding issues or concerns with other departments, including but not limited to claims processing, care management, enrollment, member services and transportation.
Executes team-based projects promptly, with routine follow-up, as needed (i.e., securing amendments to satisfy new NYSDOH directives, distribution of notifications via mail, phone, or email, execution of Nascentia directives, etc.)
Completes triennial, and as needed, desk audits of current provider records and secures re-credentialing from providers in accordance with NYS requirements. Performs site-visits as required, to all provider locations where members receive face-to-face services.
Performs site-visits and inspections at all social adult day cares within the assigned region, annually and in accordance with established OMIG requirements.
Provides community and provider education in a variety of settings to include virtual meetings, conference calls, presentations, in-services, and general drop-in/check-in visits.
Maintains working relationships with DSS and OFA contacts in the representative’s assigned counties.
All other duties as required.
Requirements
Bachelor’s degree or relevant experience in the healthcare industry.
Exposure to procedure interpretation and provider networking.
Knowledge of Medicaid managed long term care policies.
Knowledge of Medicare dual special needs plan policies.
Knowledge of ICD-9 and CPT codes desired.
Strong analytic and problem‑solving abilities.
Strong communication and negotiation skills.
Computer literacy, including but not limited to data entry, retrieval, and report generation.
Ability to drive to and from a variety of settings in varying weather conditions.
Ability to perform physical tasks which include sitting, standing, walking, pushing, pulling, climbing stairs, bending, and may include lifting a minimum of 40 pounds.
Physical Requirements
Position requires a mixture of sitting, standing, and walking.
Visual ability sufficient to read data on computer screen and paper documents.
Visual/hearing ability sufficient to comprehend written or verbal communication.
Ability to express self verbally and in writing.
Ability to drive in varied weather conditions throughout the year.
Ability to use telephone and communicate over the phone.
Bloodborne Pathogens Exposure Category III – Employee who rarely has contact with blood and body fluids.
Competitive Salary The position is an S02 exempt position with a min-max rate of: $66,129 - $76,590.
Benefits
401K with generous Employer match
On-Site Gym (free for all employees)
Tuition Reimbursement
Partially funded HSA
Employee Recognition Platform
Paid Time Off, Holidays, Sick and Extended Sick Leave
Short/Long term Disability
Employee Assistance Program (EAP)
Much More!
Nascentia Health is an Equal Opportunity Employer (EOE).
Employment is contingent upon negative results of a pre-hire drug screen.
#J-18808-Ljbffr
Applicants who reside in Jamestown, Olean, Ellicottville, Dunkirk, Houghton, and surrounding cities are encouraged to apply.
Responsible for maintaining working relationships within all vendors, both out-of-network vendors and within the provider network, as well as community relations contacts. Maintain accurate and current provider databases relating to provider facilities and credentialing information. Perform audits of electronic provider files, credentialing, contracting materials and claims submissions to ensure all contracted providers follow policies and procedures.
Performance Responsibilities and Standards
Assists in the day-to-day operations of the Provider Relations department.
Research, contacts, and works to secure agreements with vendors who provide covered services in compliance with plan requirements. Obtains new service provider application and all necessary credentialing, and forwards to Provider Relations Credentialing & Contract Management Specialists to be processed.
Prepares contracts and addendums to be executed between plan and providers.
Resolves all concerns raised by providers and provides up-to-date information on all new and existing policies and procedures.
Directs vendors to the correct contact persons at Nascentia and assists with addressing outstanding issues or concerns with other departments, including but not limited to claims processing, care management, enrollment, member services and transportation.
Executes team-based projects promptly, with routine follow-up, as needed (i.e., securing amendments to satisfy new NYSDOH directives, distribution of notifications via mail, phone, or email, execution of Nascentia directives, etc.)
Completes triennial, and as needed, desk audits of current provider records and secures re-credentialing from providers in accordance with NYS requirements. Performs site-visits as required, to all provider locations where members receive face-to-face services.
Performs site-visits and inspections at all social adult day cares within the assigned region, annually and in accordance with established OMIG requirements.
Provides community and provider education in a variety of settings to include virtual meetings, conference calls, presentations, in-services, and general drop-in/check-in visits.
Maintains working relationships with DSS and OFA contacts in the representative’s assigned counties.
All other duties as required.
Requirements
Bachelor’s degree or relevant experience in the healthcare industry.
Exposure to procedure interpretation and provider networking.
Knowledge of Medicaid managed long term care policies.
Knowledge of Medicare dual special needs plan policies.
Knowledge of ICD-9 and CPT codes desired.
Strong analytic and problem‑solving abilities.
Strong communication and negotiation skills.
Computer literacy, including but not limited to data entry, retrieval, and report generation.
Ability to drive to and from a variety of settings in varying weather conditions.
Ability to perform physical tasks which include sitting, standing, walking, pushing, pulling, climbing stairs, bending, and may include lifting a minimum of 40 pounds.
Physical Requirements
Position requires a mixture of sitting, standing, and walking.
Visual ability sufficient to read data on computer screen and paper documents.
Visual/hearing ability sufficient to comprehend written or verbal communication.
Ability to express self verbally and in writing.
Ability to drive in varied weather conditions throughout the year.
Ability to use telephone and communicate over the phone.
Bloodborne Pathogens Exposure Category III – Employee who rarely has contact with blood and body fluids.
Competitive Salary The position is an S02 exempt position with a min-max rate of: $66,129 - $76,590.
Benefits
401K with generous Employer match
On-Site Gym (free for all employees)
Tuition Reimbursement
Partially funded HSA
Employee Recognition Platform
Paid Time Off, Holidays, Sick and Extended Sick Leave
Short/Long term Disability
Employee Assistance Program (EAP)
Much More!
Nascentia Health is an Equal Opportunity Employer (EOE).
Employment is contingent upon negative results of a pre-hire drug screen.
#J-18808-Ljbffr