Network Payor Relations & Compliance Specialist (Hybrid - Jackson) - Mosaic CIN

Mosaic Clinically Integrated Network (CIN) is part of Henry Ford Health. To learn more, visit their website at

This is a hybrid position, requiring in person work 1 day a week in Jackson, MI on a regular basis, in addition to team meetings and trainings.

GENERAL SUMMARY:

Under general supervision, performs provider enrollment and compliance functions within a Clinically Integrated Network (Network). Key duties include data management, ensuring providers meet standards and regulations, processing Network credentialing applications, maintaining relationships between payors, clinics, and providers, and verifying compliance with contractual obligations. The role performs further credentialing functions including resolving claims issues, assisting with onboarding new practices, and conducting audits to ensure compliance. Responsible for creating communication materials, maintaining up-to-date payor information, and providing patient support for Medicaid redetermination and enrollment.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• Ensures providers are enrolled in the Network according to current standards and regulations and maintains stringent compliance with payors.

• Facilitates preparation for the Network Credentialing Committee, reviewing files for accuracy and completion. Works with the Committee Chair to perform the administrative review process and attain approval sign-off.

• Responsible for meeting any contractual obligations outlined within all delegated credentialing agreements held by the Network.

• Serves as the point of contact for Network practices to address claims issues with Network payors by troubleshooting on behalf of the practice and working with the payor to resolve.

• Provides enrollment assistance/support to Network provider members for non-delegated health plans as needed.

• Supports new practice onboarding by providing support pertaining to credentialing, execution of participation agreements, health plan enrollment, fee schedules, and ensure smooth transition of support to Network practice transformation team.

• Performs data entry, collection, and analysis to complete tasks supporting provider primary source verifications and enrollment processes.

• Responsible for completing various audit activities to ensure contractual compliance and satisfying NCQA standards. Audit activities include annual audits which are initiated by delegated payors, regular auditing of primary source verifications (PSV), and conducting annual audits of sub-delegate groups to the Network, such as the Henry Ford Health Central Verification Office.

• Ensures Network practice compliance and contractual obligations through comprehensive and manual validation of information (i.e., confirmation of practice hours). Performs tasks to support accurate records and roster management including:

• Network provider membership profiles within Network’s data management tool.

• Updates external provider alignment tools used to align physicians to a particular group for purposes of their quality rewards program.

• Supports Network patient alignment including but not limited to member transfer submissions and resolution tracking.

• Responsible for accurate and prompt submission of the Network provider roster to each payor using payor-specific formatting. Additional ad-hoc requests require creation of provider rosters, using variety of data platforms, for multiple use-cases.

• Maintains the Network provider roster for the Accountable Care Organization (ACO) contract including all provider additions, terminations, or changes to the ACO contract.

• Maintains current payor information, including fee schedules and policies, within the Network's SharePoint website.

• Through ongoing partnerships and collaboration with non-delegated health plans, ensures all appropriate providers are accurately aligned to Network.

• Performs outreach to patients due for Medicaid redetermination, provides education to patients on process, answers questions, assists with online forms, and provides enrollment support.

• Follows the procedures defined by Network’s patient compliant policy including reviewing patient concerns with Network administrative leadership and Network medical directors.

• Supports the Network communications and education through creating a monthly payor newsletter capturing updates from Network contracted health plans including coding, billing, prior authorizations, upcoming webinars, operations, and provides CPT coding and billing education to Network members.

• Performs ongoing evaluation, maintenance, and execution of the Network participation agreements. Maintains all policies and procedures related to Network provider affairs and delegated credentialing.

• Maintenance of the Network Behavioral Health Provider Directory.

• Attend the Network Credentialing Committee as requested by leadership.

• Payor outreach as needed on behalf of providers.

EDUCATION/EXPERIENCE REQUIRED:

• High school diploma. Associate degree preferred.

• Two (2) years of provider enrollment, provider billing, or credentialing experience.

• Demonstrated knowledge of all aspects of the insurance provider enrollment process.

• Ability to work independently, in a demanding environment, managing deadlines and competing priorities without compromising quality or accuracy.

• Meticulous, highly organized with strong business acumen, quantitative and analytical skills.

• Excellent verbal and written communication skills.

• Comfortable and competent interpreting information and making decisions.

• Demonstrated ability to interact professionally with all levels of business and clinical organizations.

• Proficient in Microsoft suite of tools including Outlook, Word, and Excel.

• Proficiency in relevant applications including EPIC, Morrisey, and/or MDStaff preferred.

CERTIFICATIONS/LICENSURES:

• Certified Professional Coder (CPC) preferred.

Additional Information

• Organization: Corporate Services

• Department: HF CIN

• Shift: Day Job

• Union Code: Not Applicable

  Additional Details

This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Henry Ford Health partners with millions of people on their health journey, across Michigan and around the world. We offer a full continuum of services – from primary and preventative care to complex and specialty care, health insurance, a full suite of home health offerings, virtual care, pharmacy, eye care and other health care retail. With former Ascension southeast Michigan and Flint region locations now part of our team, Henry Ford’s care is available in 13 hospitals and hundreds of ambulatory care locations. Based in Detroit, Henry Ford is one of the nation’s most respected academic medical centers and is leading the Future of Health: Detroit, a $3 billion investment anchored by a reimagined Henry Ford academic healthcare campus. Learn more at henryford.com/careers .

Benefits

The health and overall well-being of our team members is our priority. That’s why we offer support in the various components of our team’s well-being: physical, emotional, social, financial and spiritual. Our Total Rewards program includes competitive health plan options, with three consumer-driven health plans (CDHPs), a PPO plan and an HMO plan. Our team members enjoy a number of additional benefits, ranging from dental and eye care coverage to tuition assistance, family forming benefits, discounts to dozens of businesses and more. Employees classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.