Provider Relations Specialist

Provider Relations Specialist

Travel Percentage No Travel Category Health Care

Job Title: Provider Relations Specialist – Contracting, Credential and Load

Reports To: Provider Relations Supervisor

Job Summary:

This is a non-exempt position. The Provider Contracting, Credential, and Load Specialist has responsibility for network contracting with Professional and Ancillary providers and serving as the relationship coordinator for our PPO rental networks. The position also has responsibilities for researching and confirming credentialing information (work history, malpractice history, hospital privileges, etc.) on contracted providers. The Specialist loads both new provider information and all updates to current providers into the SIHO system and prepares files for SIHO Credentialing Committee review. Assisting our Sales, Account Management, Reinsurance, and Finance teams in understanding and quantifying our network strengths and weaknesses.

Brief Description of Duties:

• Prepare, execute, and maintain provider contracts with Professional and Ancillary providers, including renegotiation with current SIHO Network providers.
• Function as the point-of-contact for all on-going contractual issues as needed by providers.
• Negotiate Single Case Agreements (SCA) with non-participating providers as requested by Medical Management and Account Management.
• Work closely with and provide support to Health Systems Development, Sales, and Account Management to provide network support for new business development initiatives.
• Work with and provide support to Provider Services Specialists on contractual issues and to assure smooth and efficient operations.
• Establish and maintain good relationships between SIHO and its network providers
• Provide education to physicians, facilities, and ancillary providers
• Training of newly contracted health care providers on SIHO's policies and procedures
• Recognize and handle potential issues appropriately
• Handle issues within the Provider Services department internally and externally
• Complete special projects as assigned by the Provider Relations Supervisor
• Inform the Provider Relations Supervisor of important updates
• Assist in creating new projects to streamline the functions of the department
• Work with Provider Relations staff and internal/external customers to assure smooth and efficient operations
• Credential and re-credential providers by utilizing verification sources
• Enter and maintain provider load information in the SIHO system
• Coordinate with PPO Networks, Data Management, Reinsurance, and Finance to ensure our networks competitiveness is appropriately reflected in our pricing.

Qualifications

Minimum Skills Requirement:

• Experience in a managed care organization preferred
• (Internal candidates) Current SIHO performance evaluation of at least "3" (Performance achieved requirements of job.)
• Strong communication (oral and written) skills
• Demonstrated problem solving and analytical skills
• Knowledge of health insurance, billing, and/or claims processing
• Ability to work at a self-directed pace in a changing, multi-task environment
• Professional appearance and presence
• Ability to project and maintain a positive attitude internally and externally
• Intermediate understanding of Word, Excel, database, and web-based technology
• Ability to maintain strict confidentiality
• Must be good at organizing and managing multiple priorities and/or projects by using appropriate methodologies and tools.
• All positions are subject to change based on the needs of the business