Provider Network Relations Specialist - Network Business Development - Southwestern Health Resources (SWHR)

Here’s What You Need

Education

• Bachelor's Degree required, OR, Associate’s Degree with 2 years of experience in Healthcare, Health Plan, or Provider Environment in lieu of Bachelor’s Degree required.

Experience

• Require 3 years of experience in a client-facing account management role in the health care industry/payor relations (Commercial, Medicare, Medicaid) with exposure to ACO, Claims, or Payor Contracts with Bachelor’s Degree,

OR,

Require 5 years of experience in a client-facing account management role in the health care industry/payor relations (Commercial, Medicare, Medicaid) with exposure to ACO, Claims, or Payor Contracts with Associate’s Degree.

• Require 2 years’ knowledge of Billing, Coding, and Payor Reimbursement methods within health care.

Skills & Abilities

• Proficient in MS PowerPoint and ability to do presentations to large and small audiences. 
• Project Management skills, and strong planning and organizational skills.
• Project delivery methodology skills
• Exceptional facilitation skills and communicating strategies and adjusting strategies based on the feedback of stakeholders.
• Highly detail oriented with the ability to troubleshoot issues/SWHR Physician Network or Payor requests quickly and provide organizational guidance.
• Ability to hold organization as well as SWHR Physician Network or Payor accountable to deliver on operational requirements.
• Strong Data, Analytics, and Quantitative acumen.
• Familiarity with processes of CPT, HCPCS, ICD-9, coverage and reimbursement.
• Familiarity with health insurance claim forms, including CMS-1500, explanation of benefits, and prior authorization forms, and superbills charge tickets to troubleshoot cases where billing, claims submission or documentation errors may occur.
• Self-managed, self-starter with the ability to support multiple concurrent projects and meet tight delivery timelines.
• Strong Project Management approach with excellent critical thinking and problem-solving skills.
• Work requires strong knowledge in EPIC, Cactus, MS Office Suite, Salesforce, VISIO.

What You Will Do

Position Responsibilities

The Provider Network Relations Specialist is responsible for managing ACO and Fee for Service payor relationships and resolving complex global payor operational issues on behalf of SWHR Physician Network. In addition, this job is responsible for project management activities related to process workflow enhancements, educating/training SWHR Physician Network on payor agreements/requirements and chairs the Monthly/Quarterly Joint Operating Committee Meetings. The Network Relations Specialist works under minimal supervision and with considerable discretion to accomplish job responsibilities. The incumbent collaborates with the Director of Network Relations & Database Management to ensure the most effective service delivery to SWHR Physician Network. The Network Relations Specialist applies a broad range of knowledge of principles, practices, and procedures of the field, works independently, and provides leadership and may assign tasks to the Network Relations Coordinator (junior) to support Network Relations responsibilities. The work is varied and complex, blending aspects of managed care and payor contracts. This position has the authority to recommend and implement appropriate policies, procedures, and controls to ensure compliance with applicable contractual provisions, payor guidelines, regulations, and legislation.

Position Functions

• Manage Payor relationship from Leadership Level to day-to-day contacts for complex global payor operational issues, including but not limited to revenue integrity, payor policy and guideline changes, and coordination of projects.
• Develop and maintain effective relationships and regular contact with key payor stakeholders as well as executive and operational leaders within SWHR and SWHR Physician Network to ensure secure and long-term business relationships.
• Identify and provide resolution of operational issues to ensure SWHR Physician Network expectations are satisfied, coordinate implementation of solutions to prevent future issues; provide feedback and status updates.
• Serve as liaison between Payor and SWHR Physician Network operations management and organizational functional units.
• Coordinate, communicate and deliver contracted Payor information to ensure successful implementation of onboarding SWHR Physicians or modifications to existing SWHR Physicians.
• Provide SWHR Physicians and staff with educational training regarding managed care contracts, government, ACO programs and payer changes/updates, including but not limited to in-services, webinars, MCO help desk inquires, MCO Alerts, orientation materials/newsletters, presenting at centralized operational and revenue cycle meetings and maintaining all resources and tools (Managed Care Guidelines).
• Collaborate with SWHR leadership and SWHR Physician Network to identify initiatives that improve Payor efficiency and effectiveness.
• Develop, execute and report monthly/quarterly KPIs for Payor efficiency and effectiveness for the achievement of growth objectives for contracted payors.
• Makes recommendations on Payor efficiency barriers to SWHR Market & Payer Relations during open negotiations.
• Executes newly contracted Payor Offers to SWHR Physician Network (planning, communications, provides answers to inquires).
• Other responsibilities as assigned.

Why Southwestern Health Resources 

As a Southwestern Health Resources employee, you’ll enjoy, comprehensive benefits, including a 401(k) with match; paid time off; competitive health insurance choices; healthcare and dependent care spending account options; wellness programs to keep you and your family healthy; tuition reimbursement; a student loan repayment program; and more.

• Additional perks of being an SWHR employee:
• Gain a sense of accomplishment by contributing to a teamwork environment.
• Positively impact patients’ quality of life.
• Receive excellent mentorship, comprehensive training and dedicated clinical and administrative leadership resources.
• Enjoy opportunities for growth.

Explore Southwestern Health Resources Careers for more information and to search all career opportunities.

Our Recruitment team invites you to contact us with any questions at recruitment@texashealth.org

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