Medicaid Provider Relations Rep II

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

About Moda

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we're focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let's be better together.

Let's do great things, together!

Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we're focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Let's be better together.

Position Summary

This is a FT hybrid position based in Portland, Oregon. This position provides concierge customer service to providers by being the liaison between the Medicaid plans. The Provider Relations Representative is responsible for presenting, promoting, and resolving concerns and issues brought forward by providers and internal staff and develop, improve, and streamline existing provider policies with the goal of removing barriers to providing care. This role will also implement projects and policies that impact providers (includes drafting communications, frequently asked questions, resource guides) to support network needs and promote strong, collaborative relationships. This role will also plan, prepare, and develop training materials for contracted providers and will conduct face-to-face trainings throughout the year. Internally, this role will work closely with our Lead Medicaid Provider Relations Representative for other Medicaid lines of business, multiple departments and is a critical role in supporting daily operations.

Pay Range

$54,668.32 - $68,340.67 salary (depending on experience). Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Benefits

• Medical, Dental, Vision, Pharmacy, Life, & Disability
• 401K- Matching
• FSA
• Employee Assistance Program
• PTO and Company Paid Holidays

Required Skills, Experience & Education

• 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.
• Judgement, self-motivation, and the ability to work independently, and as part of a team.
• Is detail oriented and possess strong analytical, and problem-solving skills.
• Skilled at delivering trainings and facilitating meetings.
• Strong interpersonal communication skills and the ability to develop effective relationship with
• network providers, members, and partners.
• Proficiency in Microsoft Word, Excel, and PowerPoint.
• Ability to work well under pressure with frequent interruptions and shifting priorities.
• Must be willing to travel for provider training sessions.
• Knowledge of Oregon's Coordinated Care Organization (CCO) Infrastructure.
• Must be able to represent the organizations at outside meetings, conferences, and events in a positive
• and professional manner.
• Must maintain confidentiality and project a professional business image.

Preferred Skills, Experience & Education

• Knowledge of medical office workflows.
• Knowledge of other Moda Health products, plans, and networks.

Primary Functions

• 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. This includes performing research through available systems, policies, and departments, ensuring timely resolution is achieved.
• 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.
• Utilize best practice policies and procedures, work guides or tools to provide improved department process workflows.
• 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.
• Provides 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.

Working Conditions & Contact With Others

• Position is hybrid, based in Portland Oregon. Extensive close PC and keyboard work. Occasional require travel to off-site meetings which may include overnight stays.
• Internally with multiple departments. Externally with providers, providers staff, office administrators, external partners, Oregon Health Authority staff.

Together, we can be more. We can be better.

Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race, religion, color, age, sex, sexual orientation, national origin, marital status, disability, veteran status or any other status protected by law. This is applicable to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absences, compensation, and training.

For more information regarding accommodations, please direct your questions to Kristy Nehler & Danielle Baker via our [e-mail] email.