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Senior Provider Relations Consultant

Boston, MA · Healthcare
*** There is a guaranteed $1000 sign on bonus for this role, paid after 90 days on the job*****

Responsible for managing assigned territory of professional, institutional and ancillary provider types in order to enhance these relationships so that our health plan becomes their plan of choice. Serves as the primary liaison between the company and key provider organizations, taking the lead and promoting collaboration as it relates to provider network maintenance. Manages territory inclusive of one or more of highest priority network partnerships, as well as multiple other providers, facilities and community health centers. Works closely with the Provider Relations Supervisor to identify issues and report trends. Acts as liaison between provider and internal Plan departments such as Provider Enrollment, Claims, Audit, Marketing, Customer Care and Care Management.

  • Develops and enhances our physician, clinician, community health center and hospital relationships through effective business interactions and outreach
  • Works collaboratively with Provider Relations Consultants and Supervisor to develop and update provider orientation programs
  • Coaches and assists in the training of Provider Relations Consultants and Provider Relations Specialists
  • Organizes, prepares and conducts orientations of network providers (administrative and clinical) and their staff.
  • Takes the lead on specific Plan initiatives as they relate to provider education
  • Provides general instruction and support on BMCHP products and policies to providers and coordinates office and provider site clinical and administrative meetings
  • Meets with assigned providers regularly according to pre-set site visit servicing standards. Documents all pertinent provider communications and meetings in Onyx
  • Acts as liaison for all reimbursement, credentialing, claims, EDI web site procedures and issues of key providers
  • Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary
  • Works collaboratively with Contract Managers in implementing and administering contractual provisions of provider agreement to ensure contractual compliance. Monitors contractual compliance on an on-going basis
  • Manages flow of information to and from provider offices
  • Monitors and communicates market trends and issues
  • Outreaches to providers according to Plan initiatives
  • Analyzes operational issues with regard to territory and provider operations such that interrelationships among other area providers are considered
  • Facilitates timely 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
  • Represents Provider Relations and the plan at external provider and community events to maintain visible presence
  • Processes reports as needed to support provider education, servicing, credentialing and recruitment
  • Assists in developing marketing materials
  • Participates in community outreach activities and events
  • Ensures quality and compliance with state Medicaid regulations and NCQA requirements
  • Other responsibilities as assigned
  • BA/BS required or  related field, or an equivalent combination of education, training and experience
  • 4 or more year’s progressively responsible experience in provider relations or network management required
  • Must have valid driver’s license and access to reliable transportation-must live in Massachusetts.
  • Experience in the Medicare provider healthcare insurance industry required
  • Understanding of the local provider community
  • Familiarity with FACETS helpful

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