Join Martin's Point Health Care - an innovative, not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force of "people caring for people," Martin's Point employees are on a mission to transform our health care system while creating a healthier community. Martin's Point employees enjoy an organizational culture of trust and respect, where our values - taking care of ourselves and others, continuous learning, helping each other, and having fun - are brought to life every day. Join us and find out for yourself why Martin's Point has been certified as a "Great Place to Work" since 2015.
Please note that all Martin's Point Health Care employees must be fully vaccinated against COVID-19 as a condition of employment.
The Provider Relations Representative has primary responsibility for maintaining provider networks that deliver clinical, financial, and service value to Martin’s Point Health Plan members and acts as the departmental point of contact for internal and external customer relations. In partnership with Network leadership and the Network Management team, this role is responsible for maintaining ongoing positive relationships with contracted providers (network management) and managing the day to day internal work which includes the Network Management Provider email inbox, incoming faxes, prepping and QC of our provider contracts, and scanning and maintaining all department standard work and policies to ensure compliance.
The candidate's home office must will ideally be located in Northern Pennsylvania (Scranton/Wilkes-Barre areas)
- Collaborates with Network Representatives and Senior Network Representatives to identify potential providers (by market, by specialty) including gap analysis for all network expansion work
- Collaborates with Network Representatives, Senior Network Representatives, and the Manager Network Management to recruit new providers in existing markets and new expansion areas
- Acts as a liaison between internal departments to establish policies and procedures to maximize workflows
- Identifies system and processing enhancements for Claims, HMD, Provider Inquiry, and Member Services
- Maintains customer service tracker (specific to operational issues between claims, member services, provider inquiry) in coordination with customer service to enhance provider and member satisfaction
- Assists Network Representatives and Senior Network Representatives with preparation and presentation of departmental or plan audits and reviews, (e.g., CMS, TRICARE, Medicare)
- Assists with claim inquiries as it relates to provider complaints and tracks complaints into our contract system
- Maintains relationships with network providers to promote positive relationships and ensure contract compliance
- Provides education to providers through in-person visits, webinars, outreach calls or email
- Partners with Sales Team to contract with requested providers to achieve strategic member enrollment goals
- Communicates with providers to address and resolve complaints and other specific issues
- Researches and resolves Health Plan grievances presented by providers within accepted departmental timeframes to maintain compliance
- Facilitates improved workflows within the department and cross functionally
- Maintains updates to our internal process manual and employee training manual
- Ensures all provider applications are accurately completed and prepared for processing by Credentialing by ensuring provider CAQH status is current and up to date as appropriate with new/recredentialing provider applications
- Performs onsite credentialing site visits
- Supports overall Network Management production work as needed (e.g., entering provider changes
- Bachelor’s degree or equivalent combination of education and work experience
- 2+ years of experience in an administrative and/or customer service position required with experience in provider contracting and network management strongly preferred
Required License(s) and/or Certification(s):
- Valid driver’s license (no restricted or suspended license)
- Proficiency in Microsoft Word, Excel, PowerPoint and Access Office Products.
- Proficiency in CMS systems; Salesforce preferred
- Excellent interpersonal and communication skills (both oral and written)
- Ability to organize and execute multiple activities simultaneously
- Problem-solving skills
- Demonstrated and evaluated ability to work independently to meet goals
- Strong collaboration skills
- Ability to collect and manipulate data and develop presentation
- Ability to travel up to 5% of the time with potential overnights
We are an equal opportunity/affirmative action employer.