Provider Relations Representative

American Health Plans; Odessa (TX); Hybrid; USD 70,000 - 95,000; Full time

Benefits offered by this job

Health insurance

Paid time off

TeleDoc access

Disability plans

EAP

401(k) retirement

Referral bonus

Job summary

American Health Plans, a division of American Health Partners Inc., operates I-SNPs for seniors in long-term care facilities. In partnership with nursing home operators, these plans manage medical risk and reduce hospitalizations while improving patient care.

ESSENTIAL FUNCTIONS include contracting providers, credentialing, educating staff on plan operations, and maintaining provider networks. Travel to network locations is required; teleworking is possible if criteria are met.

Qualifications

• Fluent in all current provider payment methodologies including per diems, DRGs, and APCs.
• Knowledge of CMS rules and health plan operations is essential.
• Ability to educate providers on plan functions and policies.

Responsibilities

• Contract providers and vendors in current service areas to maintain CMS adequacy.
• Ensure credentialing requirements are met for service lines.
• Educate providers on Health Plan functions and roles.
• Provide ongoing educational updates as prescribed by CMS and Health Plan policies.
• Conduct education presentations for Health Plan providers to ensure understanding and commitment.
• Monitor and support provider relationships to ensure network coverage in all areas.

Skills

Provider payments

CMS knowledge

Negotiation

Time management

Communication

Team player

Independent work

Education

Bachelor's degree

Job 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

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

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

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

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.