Provider Relations Specialist-Days-LOH Behavioral Care Partners

1 week ago

Warrenville, United States NorthShore University HealthSystem Full time

Position Highlights:

  • Position: Provers Relations Specialist

  • Full time

  • Hours: 8:00-4:30

  • Location: EEH Corp Center-Warrenville

Responsible for the timely updating of provider members roster in Behavioral Care Partners (BCP) in accordance with requirements established by contracted Managed Care Organizations and National Committee Quality Assurance (NCQA). Under direction of Manager, Behavioral Care Partners is responsible for data entry of hospital admissions, Quality Improvement studies, network provider roster updates, member complaints and the triage of member complaints related to Quality/Utilization Management referral issues.

What you will do:

Credentialing:

Performs mechanics of the credentialing process for physicians in accordance with NCQA/Payor guidelines.

  • Ensures complete information on physician application.
  • Receives and monitors payor requests for documents in physician files.
  • Maintains provider contract files; ensures timely updates; maintains related tickler file.
  • Ensures provider signature for release of information and attestation.
  • Maintains summary log for each provider.

Initiates submission of documents to payors. Tracks documents and payor interaction.

  • Ensures communication with physicians regarding status of application, and participation with various payors.
  • Conducts annual audit and maintenance of physician files.
  • Maintains data entry of all behavioral health provider roster information.

Medical Management:

Provides administrative assistance to HMO Quality Improvement studies and Healthcare Effectiveness Data and Information Set (HEDIS) reports.

  • Performs data entry and maintenance of member complaint log. Triages medical management member complaints.
  • Assists with report requirements of HMO's.
  • Assists with special projects as determined by HMO's and BCP.

Other:

  • Assists in planning and strategic development for managing mental health benefits for Blue Cross HMOI medical groups:
  • Assumes responsibility to maintain and monitor department relationships with all providers
  • Identifies potential mental health providers to join the network and performs selection and recruitment.
  • Analyzes internal data relevant to specified network providers to monitor and ensure reliable financial, marketing, historical and utilization factors and terms.
  • Develops and maintains professional relationships with network providers.
  • Meets and interacts with network providers.
  • Provides and facilitates software training to new network providers.
  • Communicates contract information, benefits and terms to relative entities and provides updates.
  • Provides support to clinical case managers.
  • Provides support to members and providers for behavioral health needs. Resolves member complaints in a timely manner.
  • Utilizes advanced microcomputer software skills, (i.e., work processing, spreadsheets, graphics, databases, etc.) to update and maintain assigned areas' computer system and files necessary to support information requirements of assigned director and/or staff.
  • Types complex and routine correspondence, reports, minutes, various forms, tables, pamphlets, etc. from rough draft, handwritten notes or general verbal instructions and makes changes in grammar, punctuation or spelling as needed. Proofreads and edits drafts and final materials for appropriate and consistent format, accuracy of financial figures or other data and correct punctuation, spelling and grammar.

What you will need:

Required Education, Skills and/or Experience:

  • High School Diploma
  • High level knowledge of computer skills and financial/statistical disciplines
  • Familiarity with fees schedules such as Relevant Value Unit (RVU) and Current Procedural Terminology/Healthcare Common Procedure Coding System.

Preferred Education, Skills and/or Experience:

  • Bachelor's Degree in business, finance or healthcare
  • Minimum of one year of previous managed care experience

Benefits:

  • Career Pathways to Promote Professional Growth and Development
  • Various Medical, Dental, and Vision options
  • Tuition Reimbursement
  • Free Parking at designated locations
  • Wellness Program Savings Plan
  • Health Savings Account Options
  • Retirement Options with Company Match
  • Paid Time Off and Holiday Pay
  • Community Involvement Opportunities

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