Sr. Provider Relations Representative

Description

Summary/Position Objectives: 

Under the supervision of the Director of Provider Relations & Data Management this position is responsible for addressing provider issues and applying resolutions, responding to provider telephonic and written inquiries in an accurate and timely manner for participating providers and non-participating providers. The senior representative trains new and existing providers in MPC policies and procedures and completes provider on-site audits. 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.

About Maryland Care Management, Inc. (MCMI)

Maryland Care Management, Inc. (MCMI) manages 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 1996, and we are proud of our footprint in the community. With over 230,000 members, MPC consistently has been one of MD's largest Medicaid-managed care organizations.

Why join us?

MCMI recognizes the importance of flexibility and offers multiple work arrangements. Along with competitive pay, we offer excellent benefits (medical, dental, and vision plans, 100% employer Term Life Insurance, Short and Long-Term Disability, 401k Employer Match up to 4%) as well as 20 days of PTO, and tuition assistance/professional development plans. 

Your future colleagues at MCMI are welcoming, friendly, and eager to help each other succeed. We are committed to Diversity, Equity, and Inclusion, providing organizational-wide social opportunities, and constantly improving our ongoing efforts to positively impact our members' lives.

What You'll Do:

• Develops and maintains positive provider relationships to assist in provider network maintenance and growth.
• Manages complex provider specialties and large provider systems.
• Responds timely to incoming provider calls, serving as the primary provider liaison.
• Serves as knowledge and resource expert regarding resolution of provider issues.
• Researches provider disputes related to claims and member issues.
• Responds to escalated provider issues.
• Responds to provider correspondence in a thorough and timely manner.
• Tracks and responds to provider grievances and appeals.
• Conducts provider site visits/audits.
• Monitors 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.
• 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:

• 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.

Requirements

Knowledge:

• Knowledge of provider relations.
• 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 facts, draw valid conclusions, and design, implement, and manage appropriate action plans.
• Ability to successfully utilize business application software, Microsoft Office suite, and common computer and office hardware.

 Requirements: 

• Bachelor’s degree in business, health, management systems, or related discipline (preferred)  
• 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. 
• Must possess reliable transportation with proper insurance coverage and be available for travel both in and out of state.