Provider Relations Representative
Maryland Care Management Inc.
/Maryland Physicians CareProvider Relations Representative (Central Maryland Region)MCMI is responsible for managing Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians.
Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 2006 and is proud to be celebrating its 25th anniversary.
With over 230,000 members, MPC consistently has been one of the third largest managed care organizations in MD.
All incumbents must be fully vaccinated prior to hire and able to commute to the Linthicum office as needed.
Summary/Position Objectives:
Under the supervision of the Manager of Provider Relations, this position is responsible for addressing provider issues and applying resolution, responding to provider telephonic and written inquiries in an accurate and timely manner for participating providers and non-participating providers in Central Maryland.
Additionally, this position delivers provider relations support to internal departments including but not limited to Network Management, Quality, Compliance, and Medical Management.
The senior provider representative also provides training and mentoring to new provider relations representatives as well as leads small projects for the department.
Essential Functions :
Develops and maintains positive provider relationships to assist in provider network maintenance and growth.
Responds timely to incoming provider calls, serving as the primary provider liaison.
Serves as knowledge and resource expert regarding resolution of provider issues.
Trains providers and internal staff regarding MPC systems, processes and benefits; conducts follow-up training to ensure policy compliance and education continuity; disseminates written correspondence as necessary to address issues, problems and new information, as needed.
Researches provider disputes related to claims and member issues.
Responds to escalated provider issuesResponds to provider correspondence in a thorough and timely manner.
Tracks and responds to provider grievances and appeals.
Conducts provider site visits/audits.
Participates in internal Provider Relations auditsLeads provider relations projects under the supervision of the Provider Relations ManagerMonitors provider availability and accessibility, including coverage and response time to service requests.
Assists with onsite contractual reviews; ensures 100% accuracy and timeliness of information/modification data entry in provider files.
Generates reports, as needed.
Provides training to providers and staff in user specific areas of referral network and procedures, pre-authorization, coding, (ICD-9, HCPC, CPT-4) and billing (CMS 1500, UB04).
Secondary Functions:
Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
Maintains regular and acceptable attendance at such level as is determined in the employer's sole discretion.
Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs.
Maintain professionalism, including phone etiquette, manners, appearance, and attitude.
Maintain effective working relationships with various providers, networks, and managed health care components.
Continue education regarding changes and trends in health care management and specific provider communities.
Other duties as assigned.
Knowledge and Skills:
Knowledge of provider relations.
Excellent interpersonal skills.
Strong problem-solving skills.
Ability to train effectively.
Excellent project management skillsExcellent verbal and written communication skills.
Ability to present information effectively in one-on-one and small group settings to providers and employees.
Ability to use reason to define problems, collect data, establish fact, draw valid conclusions, and design, implement, and manage appropriate action plans.
Ability to multi-task and organize and coordinate priorities.
Ability to be a positive team player able to manage project time constraints and work with little supervision.
Ability to successfully utilize business application software, Microsoft Office suite and common computer and office hardware.
Education and Work
Experience:
Bachelor's degree in business, health, management systems or related discipline preferred with a minimum of three (3) years' experience with provider relations.
Experience with physician providers, medical terminology, common coding, and billing requirements is required.
Demonstrated experience with claims processing and research required; advanced interpersonal skills, maturity, and good judgment is required.
Must possess reliable transportation with proper insurance coverage and be available for extensive travel both in and out of state.
This position requires work experience in a complex and competitive environment.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
/Maryland Physicians CareProvider Relations Representative (Central Maryland Region)MCMI is responsible for managing Maryland Physician Care's (MPC) statewide provider network of hospitals and physicians.
Maryland Physicians Care has been providing services to the HealthChoice Medicaid populations since 2006 and is proud to be celebrating its 25th anniversary.
With over 230,000 members, MPC consistently has been one of the third largest managed care organizations in MD.
All incumbents must be fully vaccinated prior to hire and able to commute to the Linthicum office as needed.
Summary/Position Objectives:
Under the supervision of the Manager of Provider Relations, this position is responsible for addressing provider issues and applying resolution, responding to provider telephonic and written inquiries in an accurate and timely manner for participating providers and non-participating providers in Central Maryland.
Additionally, this position delivers provider relations support to internal departments including but not limited to Network Management, Quality, Compliance, and Medical Management.
The senior provider representative also provides training and mentoring to new provider relations representatives as well as leads small projects for the department.
Essential Functions :
Develops and maintains positive provider relationships to assist in provider network maintenance and growth.
Responds timely to incoming provider calls, serving as the primary provider liaison.
Serves as knowledge and resource expert regarding resolution of provider issues.
Trains providers and internal staff regarding MPC systems, processes and benefits; conducts follow-up training to ensure policy compliance and education continuity; disseminates written correspondence as necessary to address issues, problems and new information, as needed.
Researches provider disputes related to claims and member issues.
Responds to escalated provider issuesResponds to provider correspondence in a thorough and timely manner.
Tracks and responds to provider grievances and appeals.
Conducts provider site visits/audits.
Participates in internal Provider Relations auditsLeads provider relations projects under the supervision of the Provider Relations ManagerMonitors provider availability and accessibility, including coverage and response time to service requests.
Assists with onsite contractual reviews; ensures 100% accuracy and timeliness of information/modification data entry in provider files.
Generates reports, as needed.
Provides training to providers and staff in user specific areas of referral network and procedures, pre-authorization, coding, (ICD-9, HCPC, CPT-4) and billing (CMS 1500, UB04).
Secondary Functions:
Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
Maintains regular and acceptable attendance at such level as is determined in the employer's sole discretion.
Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs.
Maintain professionalism, including phone etiquette, manners, appearance, and attitude.
Maintain effective working relationships with various providers, networks, and managed health care components.
Continue education regarding changes and trends in health care management and specific provider communities.
Other duties as assigned.
Knowledge and Skills:
Knowledge of provider relations.
Excellent interpersonal skills.
Strong problem-solving skills.
Ability to train effectively.
Excellent project management skillsExcellent verbal and written communication skills.
Ability to present information effectively in one-on-one and small group settings to providers and employees.
Ability to use reason to define problems, collect data, establish fact, draw valid conclusions, and design, implement, and manage appropriate action plans.
Ability to multi-task and organize and coordinate priorities.
Ability to be a positive team player able to manage project time constraints and work with little supervision.
Ability to successfully utilize business application software, Microsoft Office suite and common computer and office hardware.
Education and Work
Experience:
Bachelor's degree in business, health, management systems or related discipline preferred with a minimum of three (3) years' experience with provider relations.
Experience with physician providers, medical terminology, common coding, and billing requirements is required.
Demonstrated experience with claims processing and research required; advanced interpersonal skills, maturity, and good judgment is required.
Must possess reliable transportation with proper insurance coverage and be available for extensive travel both in and out of state.
This position requires work experience in a complex and competitive environment.
.
Estimated Salary: $20 to $28 per hour based on qualifications.
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