Provider Account Specialist-Cross Functional (Remote Option)

Competitive Compensation & Benefits Package!  

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

See attachment for additional details. 

Location:   Remote option; Available for any of Partners' locations

Projected Hiring Range:  Depending on Experience

Closing Date:  Open Until Filled

Primary Purpose of Position:   This position assists in the development, support, and management of the provider network for both physical health and behavioral health. This Cross-Functional Provider Network Account Specialist is responsible for developing, maintaining and servicing a high quality, marketable and satisfied provider network for Partners Health Management. This position is expected to build and sustain strong working relationships with cross functional departments, physical health plan partners, and both behavioral and physical health providers. The Cross-Functional Provider Account Specialist supports successful operations of behavioral and physical health providers within our healthcare delivery model by providing strategic education on the special needs of the enrollees, a comprehensive understanding of the contract, and serves as a liaison with other Partners’ health plan partners that the provider works with. This position provides heavy liaison and communication support for EVV for both Physical Health and Behavioral Health providers.

Role and Responsibilities:  

• Account Specialist Roles and Responsibilities:
  • Educating the providers to ensure they understand the contract and the Medicaid initiatives regarding this population and the contract requirements
  • Communicates and collaborates to mitigate issues and risks around providers and Physical health vendors, EVV vendors, CVS/Caremark, NEMT, LTSS and others as assigned.
  • Educating the providers to the mandated best practices for their provider type and the quality measures. 
  • Coordinates with internal departments to mediate and resolve provider questions or issues regarding prior authorizations, claims submission, EVV, LTSS, or payment issues.
  • Handles or ensures appropriate scheduling, agenda, materials, location, of provider meetings as needed.
  • Collaborates with other departments to ensure provider data is correct and includes any needed updates.
  • Assists providers to obtain and complete Provider Change Forms as needed. Provides information and participates in management meetings as requested.
  • Enhance account relationships by investigating, documenting, and resolving provider matters and effectively handling and responding to account changes and correspondence.
  • Provide information and status updates for providers regarding incentive agreements and how to maximize their performance.
  • Regularly meets with other internal departments to create, revise and adjust strategy for assigned provider groups to meet overall performance goal. 
  • Assists with development and implementation of contracts for agencies and licensed independent practitioners.
  • Reviews and Signs-off on Provider Invoices as assigned.
  • Chair, Co-Chair, and Participate in internal and external committees.
  • Capable of working with all levels of the organization including Executive Leadership Team, Departmental Directors, and Managers to assist with problem resolution. 
  • Active Participation other department subgroups/initiatives to further network development and adequacy
  • Oversight of identified performance measures with providers. 
  • Work with finance to track and monitor utilization of all funding mechanisms.
  • Technical Assistance-Assisting providers as needed with our internal systems-authorization, claims, alpha issues.
  • Provides support for LTSS providers and assists with issues, concerns, and resolution around LTSS providers.
  • Provides support for NEMT providers and assists with issues, concerns, and resolution around NEMT providers.
  • Coordinate meetings with Providers and Internal staff when needed.
  • Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed.
  • Participate in internal workgroups that involve existing providers.  
  • Assist with Identifying & developing provider training to meet provider needs.
  • Assigned to physical health, EVV, LTSS initiatives, and other special populations as identified and indicated. 
  • Development of Policy & Procedure, and notifications associated with Contract Performance monitoring.
  • Responsible for pulling multiple reports from ALPHA/Report Manager and/or other databases to share with providers for them to improve upon.
  • Participation in internal and external committees, as assigned.
• EVV Roles and Responsibilities
  • Provides heavy support to the EVV system by responding and mediating provider concerns. 
  • Collaborates with internal departments, external vendors, and other payer plan partners to ensure that EVV is working as anticipated, providers are being paid timely.
  • Conducts internal and provider meetings to share and discuss issues of concern, troubleshoots for issue resolution, and implements an escalation process for discrepancies.
  • Trends and tracking for EVV concerns, issues, and resolution.

Knowledge, Skills and Abilities: 

• Considerable knowledge of the laws, regulations and policies that govern the program
• General knowledge of Physical Health business practices, rules, and regulations
• Exceptional interpersonal and communication skills
• Strong problem solving, negotiation, arbitration, and conflict resolution skills
• Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint
• Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws, rules and regulations to various situations; to apply regulations and policies for maintenance of consumer medical records, personnel records, and facility licensure requirements
• Ability to make prompt independent decisions based upon relevant facts
• Ability to establish rapport and maintain effective working relationships
• Ability to act with tact and diplomacy in all situations
• Ability to maintain strict confidentiality in all areas of work

Education/Experience Required: Bachelor's degree in health care administration, business administration, accounting, finance, or human services, and five (5) years of experience in provider network management, health care insurance or other health care delivery setting. A combination of relevant experience may be considered in lieu of a bachelor’s degree. 

Must be able to travel as needed to perform job duties. 

NC residency is required.

Education/Experience Preferred:  Master's degree in business administration or human services and two years’ experience in a physical health or clinical environment.  Clinical licensure preferred. Experience with Physical Health Services and business operations, Electronic Visit Verification, preferred but not required.