Hybrid Medicaid Provider Relations Specialist

Moda Health; Portland (OR); Hybrid; USD 55,000 - 68,000; Full time

Benefits offered by this job

401K Matching

Medical, Dental, Vision

Life, & Disability

FSA

PTO & Holidays

Job summary

Moda Health in Portland, Oregon, seeks a Provider Relations Representative for Medicaid who will liaise between Medicaid plans and providers and support policy improvements. The role includes developing training materials, drafting communications, and coordinating provider initiatives.

The position requires 3+ years in provider relations, knowledge of Medicaid policies, and strong analytical and training skills. Hybrid work with travel for trainings is expected; salary ranges based on experience.

Qualifications

• Three or more years of provider relations experience.
• Requires expertise in industry practices, specialized payment methodologies, Value Based Care agreements, Payer/Provider Strategic Partnerships, and all relevant regulations.
• College degree in health care, business, analytics, or related field, or equivalent work experience.
• Knowledge of Medicaid claims and benefits.
• Proficient in identifying and interpreting Oregon Administrative Rules, CCO and provider contracts.
• Knowledge of provider payment methodologies including capitation, DRG, CAH and other facility and professional pricing.
• Ability to analyze and validate provider claims and payment data.
• Experience in manual processing of high dollar checks.
• Must be willing to travel for provider training sessions.
• Knowledge of Oregon's Coordinated Care Organization (CCO) Infrastructure.

Responsibilities

• Assist leadership in negotiating Single Case Agreements; review contract terms to ensure they can be operationalized.
• Validation of bi-annual Delivery System Network (DSN) Report in partnership with analytics.
• Assists with state, federal and other entity related audits.
• Contract configuration, implementation, validation, and assessment.
• Implement and coordinate new Medicaid provider focused initiatives.
• Identify root causes of claim problems and trends and participate in developing solutions.
• Work in a consultative role with various departments creating effective processes and updates.
• Review and update Medicaid provider manuals, policies and procedures as well as desk manuals.
• Oversight and management of Medicaid provider webpage content.
• Coordinate and participate in targeted provider meetings, including annual Provider Workshops.
• Educate providers on Oregon Administrative Rules and contract language ensuring consistent interpretation.
• Provide timely responses to all provider inquiries, within two to three business days.
• Provide ongoing support to the Medicaid Operations team.
• Process provider enrollment applications and meet timelines established by management.
• Complete and validate Medicaid encounter data.
• Conduct on-site provider visits to create strategic provider partnerships to improve health efficiencies, and foster provider experience.
• Attend State and other Medicaid related meetings to learn about new policy and initiative changes that have an impact on operations.
• Perform other duties and special projects assigned.

Skills

Provider relations

Medicaid knowledge

Analytical skills

Communication skills

Travel willingness

Education

College degree

Tools

Microsoft Word

Microsoft Excel

PowerPoint

Job description

Moda Health in Portland, Oregon, seeks a Provider Relations Representative for Medicaid who will liaise between Medicaid plans and providers and support policy improvements. The role includes developing training materials, drafting communications, and coordinating provider initiatives.

The position requires 3+ years in provider relations, knowledge of Medicaid policies, and strong analytical and training skills. Hybrid work with travel for trainings is expected; salary ranges based on experience.