Network Management Representative

4 weeks ago

Honolulu, United States CareerBuilder Full time

Responsible for initiating and providing face-to-face support to new providers interested in joining HMSA's network. This includes, but is not limited to, contracting and on-boarding to ensure that there are no unnecessary delays in the process. It involves conducting new provider orientation & on-going training related to claims filing, E-Library, HHIN, reimbursements. Applying problem-solving techniques as it relates to dispute resolution to include, but not limited to, HMSA's provider contract definition, application of payment or medical policies, provider operations that involve posting claims payments, and complaints made through the Insurance Commissioner's office within timeframes required by the Insurance Division or by HMSA as stated in the provider contract.

Through positive direct in-person interactions with providers, build a collaborative and trusting relationship that leads to understanding, alignment and buy-in to HMSA programs and processes. Conducts proactive and requested field visits to provider's offices to gain market intelligence, support, drive behavior change, and provide guidance on HMSA business initiatives including, but not limited to, changes in claims processing, reimbursement, policies, promotion of self-service tools, and support of various complex HMSA programs. Participates and attends Community or Provider sponsored events representing HMSA in support of a viable, accessible provider network.

Develops the content and coordinates with educators and SME's as appropriate to maintain and implement operational content used to train both Provider Servicing staff and Providers' business offices. Coordinate and conduct education activities involving providers, Provider Services and other HMSA departments with the objective to modify inefficient claim filing behaviors and to implement operational business changes. Supports development and implementation of policy changes on behalf of Provider Services and communicates the provider perspective when representing the department on cross-functional teams, corporate initiatives, and tactical objectives.

Works with Network Management analyst to identify and fill network gaps and propose strategies to fill gaps through the following actions:

Recruitment of new providers by researching and developing relationships with non-contracted providers to build a cost-effective, high quality provider network

Expansion of current providers via additional locations, panel growth, or new technology.

Coordinates case resolution with internal business areas to respond (in writing, telephonic, or face-to-face) timely and accurately to provider inquiries regarding claims, benefits and complex issues that include medical or payment policy questions and provider appeals. Proactively resolve problems to ensure compliance with contract terms and resolve problems due to system programming to build trust and strong business relations with all providers.

Performs all other miscellaneous responsibilities and duties as assigned or directed.

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