Provider Relations Representative

American Health Communities; Hattiesburg (MS); Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Affordable medical/vision insurance

Generous paid time off

TeleDoc 24/7/365 access to doctors

Disability plans

Employee Assistance Plan (EAP)

401K retirement accounts

Employee Referral Bonus Program

Job summary

American Health Plans, a division of American Health Partners Inc., operates Medicare Advantage I-SNPs for seniors in long-term care facilities. The role focuses on contracting providers, credentialing, and educating networks to meet CMS requirements and ensure strong membership care.

The position involves travel to network locations, teleworking options if criteria are met, and collaboration with multiple teams to maintain network adequacy and quality services.

Qualifications

• Experience with provider contracts and credentialing for CMS programs.
• Understanding of CMS rules and Health Plan policies.
• Ability to educate providers about plan functions and benefits.

Responsibilities

• Contract providers and essential vendors in current service areas to maintain CMS adequacy and provide necessary services.
• Ensure providers meet credentialing requirements for their service lines.
• Educate providers on Health Plan functions and roles; provide CMS guidance updates.
• Conduct ongoing educational updates per CMS and plan policies.
• Deliver education presentations to ensure provider understanding and commitment.
• Maintain provider relationships to ensure network coverage in all areas.
• Collaborate on implementation and process improvements.
• Complete corporate assignments as assigned.

Skills

Provider payment methods

Medical services knowledge

Independent work

Negotiation

Communication with medical staff

Teamwork

Self-motivation

Education

Bachelor's degree

Job description

American Health Plans
Hattiesburg, MS 39401, USA

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

ESSENTIAL FUNCTIONS

To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation

• 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

  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.

  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.