Provider Relations Representative

American Health Plans; Fort Worth (TX); Hybrid; USD 65,000 - 90,000; Full time

Benefits offered by this job

Affordable Medical/Dental/Vision

Generous paid time-off and holidays

TeleDoc 24/7/365 access to doctors

Optional short- and long-term/disabilt

Employee Assistance Plan (EAP)

401K retirement accounts

Employee Referral Bonus Program

Job summary

American Health Plans in Fort Worth, TX seeks a Market Contracting Analyst to support provider contracts and CMS adequacy across current service areas. You will educate providers, maintain relationships, and report market changes to Health Plan leadership.

The role emphasizes collaboration with providers and vendors, ensuring credentialing compliance, and contributing to process improvements while traveling to network locations as needed.

Qualifications

• Experience in the health care field required.
• Prior experience in network development / network services preferred.
• Bachelor’s degree or 3 years of managed care experience required.

Responsibilities

• Contracting providers and essential vendors to maintain CMS adequacy.
• Ensure providers meet credentialing requirements for service lines.
• Educate providers on Health Plan functions and roles.
• Provide ongoing CMS and Health Plan policy updates.

Skills

Provider payment methodologies

Provider credentialing

Provider relations

Negotiation

Communication with medical staff

Team collaboration

Independent work

Education

Bachelor’s degree in Healthcare Administration or related field OR 3 years of managed care network development experience

Job description

American Health Plans
Fort Worth, TX, USA

Description

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, and Mississippi, Louisiana, Iowa, and Idaho with planned expansion into other states in 2024. For more information, visit AmHealthPlans.com.

Benefits and Perks include:

• Affordable Medical/Dental/Vision insurance options
• Generous paid time-off program and paid holidays for full time staff
• TeleDoc 24/7/365 access to doctors
• Optional short- and long-term disability plans
• Employee Assistance Plan (EAP)
• 401K retirement accounts
• Employee Referral Bonus Program

POSITION SUMMARY

The purpose of this position is to analyze assigned existing market needs, performs some standard contracting functions, educates providers and provider service entities, maintain business relationships for the Health Plan(s), reports on provider and market changes, acts as a support for other service areas for the Health Plan(s).

ESSENTIAL FUNCTIONS

• Contracting providers and essential vendors in current service areas to maintain CMS adequacy and providing necessary services in the care of the Plan members
• Insuring providers and essential vendors in current service areas meet the credentialing requirements for their appropriate service lines
• Educating providers on the Health Plan(s) functions and roles in caring for its membership
• Ongoing educational updates as prescribed by CMS and the Health Plan(s) policies
• To conduct the education presentations of the Health Plan(s) providers to insure their understanding and commitment with the Health Plan(s)
• Monitor, maintain and support provider relationships to insure network coverage in all areas
• To work with and be involved in implementation as needed
• Establish a positive work environment that encourages participation in process improvement and commitment to department/company success
• Complete corporate assignments as assigned

Required Skills

• Must be fluent in all current provider payment methodologies including per diems, DRGs, and APCs
• Must have knowledge and familiarity with all levels of medical services and ability to rapidly develop working relationships
• Must be able to accept instructions and work independently in the completions of goals and assignments
• Must have strong negotiation, organization, presentation and time management skills
• Must be able to effectively communicate with all levels of medical staff to explain Health Plan(s) program, benefits and goals
• Must be able to work effectively in a team environment
• Must be self-motivated, dependable, team and goal-oriented

Required Work Experience

• Experience in the health care field required
• Prior experience in network development / network services is preferred
• Prior experience with acute and post-acute facilities is beneficial
• Prior experience with Medicare Advantage plans is helpful

Licensing/Certification/Education Requirements

• Bachelor’s degree, with emphasis in Healthcare Administration/related field or three (3) years of experience in managed care network development/network services

Other Requirements

• Must be available to work 8 a.m. until 5 p.m. local time
• Position requires travel to network provider locations.
• Teleworking is an option if criteria are met

EQUAL OPPORTUNITY EMPLOYER

Our Organization does not discriminate based on race, color, religion, sex, handicap, disability, age, marital status, sexual orientation, national origin, veteran status, or any other characteristic(s) protected by federal, state, and local laws. The Organization will also make reasonable accommodations for qualified individuals with disabilities should a request for an accommodation be made.

This employer participates in E-Verify.

Qualifications

Education

Required

Bachelors or better.

Equal Opportunity Employer
This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.