IPA, Network Provider Specialist [HOUSTON]

The IPA, Provider Network Specialist manages the physician network by developing and maintaining the assigned IPA/Medical Group. This individual provides service and education to network physicians/providers and achieves company targets by implementing network improvement plans. The representative offers professional work and is responsible for performing activities pertaining to IPA Provider Network Specialist. This job includes traveling to provider offices and working under general supervision. Positions at this level are assigned a broad range of duties in the occupation. The representative uses judgment in selecting appropriate guidelines and applying general policies and procedures.

ROLE TYPE: On the road
 

RESPONSIBILITIES

• Completes new provider orientation for all applicable product lines.
• Conducts provider group meetings to review monthly/quarterly data and outcomes.
• Responsible for meeting minutes and follow-up on 'TO DO' items identified at meetings.
• Conduct site visits to service providers, resolve issues, educate staff and providers on policies, and collect credentialing information.
• Conduct site visits to service providers and educate staff and providers on submitting Risk Adjustment Factor Data and HEDIS information.
• Maintains relationships with contracted HMOs to implement amendments to DOFR, delegation, policy, and procedures.
• Returns all routine calls from providers within 24 hours to establish consistent and robust relationships with provider offices.
• Provide oversight on inquiries and claims issues and follow up with providers to ensure problems have been resolved.
• Maintains provider office tools, including provider manual.
• Supports regional Network Improvement Plan targets by providing utilization reports, ER contingencies, Frequent Flier Reports, and other analytics available to improve /maintain regions.
• Identifies network gaps and completes contracts for PCP, Specialist, and Ancillary networks with in-depth knowledge of different fee schedules (Medicare/Medical/ASP/AWP).
• Identifies new cost-saving possibilities through working with various committees, such as UM and Claims.
• Understands and explains risk contracts (shared risk/entire risk).
• Strategizes for membership growth and retention.
• Provide training, mentoring, and guidance to new representatives.
• Works on special projects as assigned or directed.
   

QUALIFICATIONS

• Knowledge of MS Office: Word, Excel, PowerPoint, Access Database.
• Knowledge of MS Provider relations/customer service strategies.
• Knowledge of MSO-VL and MMSE programs and services: Authorizations, Claims, Credentialing encounters, RAF, Star Ratings, IS/IR, etc.
• Knowledge of Network development strategies and Provider Relations experience or similar background.
• Knowledge of current MSO-VL and MMSE geo-access requirements.
• Effective and efficient oral and written communication skills.
• Knowledge of County provider demographics.
• Skills in negotiating contract language and rate structures.
• Skills to provide training and technical assistance to contracted providers.
• Skills to evaluate and assess provider network to determine gaps and services needed.
• Skills to identify and develop new providers to ensure accessibility.
• Skills to monitor contract performance through site visits and data analysis.
• Skills to facilitate contracted provider meetings.
• Ability to represent the department or division professionally.
• Ability to establish and maintain effective working relationships with contracted and potential providers.
• Ability to resolve provider inquiries or requests promptly.
   

REQUIREMENTS

• Bachelor's Degree in Marketing or Business Administration
• Minimum of 2 years experience in Network Management within a managed care environment, health plan, or significant medical group administration.
   

BENEFITS:

• 401(k) matching
• Dental insurance
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Vision insurance