Lead Provider Partnership Associate

The Provider Network Services Lead Provider Partnership Associate supports Integrated Delivery Health Systems (IDS) and community providers including but not limited to primary care physicians, specialists, ancillary, behavioral health, and institutional providers in Pennsylvania and Delaware.  Independently researches, analyzes, and addresses provider issues and concerns to achieve expected goals/outcomes within the set timeframes.  Proactively educates providers on new initiatives and policy changes that impact their claims payments, including outreach for UM Vendor Management Programs.  Establishes and maintains professional and effective relationships between IBC and network providers to continually improve provider satisfaction.  Ensures the resolution of issues related to complex claims payment, provider data file maintenance, Quality Incentive Payments (QIPS), capitation, and medical policy.  Maintains and updates the appropriate tracking issues database with current statuses and next steps.  Collaborates with other departments within the organization to assist with the resolution of complex provider issues. Works collaboratively with Contracting and Reimbursement to support decisions and negotiations during the recontacting process.  Establishes and maintains professional and effective relationships between IBC and these providers to continually improve provider satisfaction.

MAJOR ACTIVITIES:

·       Independently supports health systems and services community providers, including but not limited to primary care physicians, specialists, ancillary, behavioral health, and institutional providers.  Educates providers concerning new initiatives and policy changes that impact their claims payments.

·       Organizes and conducts initial orientations and servicing meetings as needed with defined providers. 

·       Handles Provider Validation Roster requests within established timeframes.  Ensures completion/submission of all necessary change forms to support the Provider Roster Validation process.

·       Ensures that key goals and objectives are accomplished in keeping with established priorities and timeframes.

·       Continuously develops technical skills to support servicing overly complex provider issues across all provider types.

·       Independently performs research and analysis of all provider issues received both externally and internally, including but not limited to claim payments, provider data file discrepancies, Quality Incentive Payments (QIPS), capitation, medical policy, utilization management, and other compliance initiatives. Addresses provider issues and concerns to ensure that expected goals/outcomes are achieved within the set timeframes.

·       Maintains and updates the appropriate tracking issues database with current statuses and next steps.

·       Conducts root cause analysis and collaborates with staff in other business areas to assist with the resolution of complex provider issues and achieve expected goals/outcomes within established timeframes, requesting the support of management when needed. 

·       Uses the information gained during servicing activities to make recommendations to management regarding the identification of significant opportunities to improve operational efficiency, reduce costs, and improve provider satisfaction. 

·       Provide key insights and recommendations to improve provider experience and minimize future servicing issues during contract negotiations.

·       Establishes and maintains professional and effective relationships between IBC and practice administrators, medical directors, and practitioners to ensure compliance with contractual obligations, applicable State & Federal regulatory requirements, accreditation standards, and corporate policies.

·       Develops and maintains professional and effective relationships with various levels of management within IBC to achieve successful outcomes.  Identifies policies and procedural issues and recommends potential resolutions by working with management.

·       Completes assigned projects to support corporate initiatives within the timeframe set by Management.

·       Supports other members of the team to ensure that service levels and goals are met.

·       Represents department and serves as a liaison on corporate initiatives and project workstreams.

·       Recommends inventory mitigation strategies during high-volume peak workloads and/or post-production or system implementation.

·       Performs other duties as assigned.