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HealthOne Alliance · 3 months ago

Provider Engagement Representative

Dalton, Georgia

Full-time

Onsite

New Grad, Entry Level

HealthOne Alliance is committed to enhancing well-being by connecting individuals with vital health resources. The Provider Engagement Representative will service providers through education, communication, and support, ensuring compliance with company policies and Medicaid CMO communication protocols.

Health CareHealth InsuranceHospitalMedical

Responsibilities

Works directly with providers to ensure they are serviced, maintained, and educated on all policies and procedures in an efficient and professional manner

Manages collaboration with other departments and outside entities to meet identified needs of the providers and their patients, while also ensuring that other staff cooperate with these entities

Provides positive, supportive communication to providers at all times

Provides content for the Provider Insider Newsletter to ensure approved messages and communication comply with Provider Notification requirements

Acknowledges any grievances and complaints within 1 business day of notice and resolves the issue within 30 days. All notes and communication are clearly documented within the appropriate workflow to ensure adequate tracking of the resolution of the complaint

Assists with ensuring providers are compliant with the NCQA requirements regarding availability and access standards and also evaluates the standards to ensure they address the requirements outlined by NCQA

Facilitates provider surveys and communications required for NCQA compliance

Provides education, coaching and guidance to providers regarding HEDIS measures, CMS programs and any other quality initiatives for members

Gathers provider opt-in forms for various contracted entities that fall under HOA (Medicaid CMOs, Tricare, PHS/CI, etc.)

Assists Contracting, Credentialing and Network Management in loading new providers and completing contract/credentialing files

Works with Network Management to ensure provider updates are sent for processing timely and ensures updates are performed accurately within the system

Assists in research and problem resolution on issues related to claims processing incorrectly and works with the Claims Department to find resolution

Reviews claim reports for denials and works with providers to improve claim submissions and provider data updates to ensure accurate claim adjudication

Creates, audits, and distributes provider reporting as necessary

Facilitates messenger model activities with health plan partners

Encourages web-site and provider portal utilization through education and training to ensure providers can maximize the website and portal to best service their practices and patients

Maintains provider and patient confidentiality at all times

Keeps current in changes and trends that affect the Managed Care Industry

Maintains regular and predictable attendance

Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice

Works to encourage and promote Company culture throughout the organization

Other duties as may be assigned