Analyzes qualitative and quantitative data to support negotiating strategies and rate decisions, utilizing financial modeling for all contract negotiation rate decisions. Conducts network analysis in support of provider network goals and assesses financial implications of contract business terms. Makes recommendations on network development initiatives based on this analysis Acts as an information source for all Amerigroup staff on network relationships, contractual arrangements, and issues. Works closely with Provider Relations and other Network Development Division staff on appropriate recruitment, provider database set-up, administrative and customer service activities. Develops and maintains positive, constructive, mutually beneficial relationships with potential and active network providers, as well as Affinity staff, in order to assure effective communication, prompt problem resolution, and maintenance of consistently positive working relationships. Provides accurate information to providers and Affinity staff on applicable regulatory and statutory requirements. Maintains thorough, accurate, timely documentation of activities, tasks, and provider contracts. Demonstrates proficiency with the principles and methodologies of process improvement. Applies these in the execution of responsibilities in support of a process focused approach. Performs other duties or responsibilities as necessary or assigned.

SERVE THE HEALTH PLAN BY RECORDING, TRACKING, RESOLVING AND EXPEDITING CLAIM PROCESSING PROBLEMS IN PRIORITY SEQUENCE DETERMINED THE NEW YORK HEALTH PLANENSURE APPROPRIATE APPROVALS AND DOCUMENTATION OF EACH PROJECTSUPPORT THE FINANCIAL REPORTING OF HEALTH PLAN PROJECTS OVER $5K.SERVE AS PRIMARY CONTACT WITH CLIENT TO ENSURE COMMUNICATION IS MAINTAINED AND PROJECT SCHEDULES ARE ADHERED TO.DEVELOP AND MAINTAIN GOOD COMMUNICATION AND WORKING RELATIONSHIPS WITH INTERNAL AS WELL AS EXTERNAL TEAMS. ANTICIPATE BOTTLENECKS, PROVIDE ESCALATION MANAGEMENT, ANTICIPATE AND MAKE TRADEOFFS, AND BALANCE THE BUSINESS NEEDS VERSUS TECHNICAL CONSTRAINTS.DEVELOP, UPDATE, AND MAINTAIN PROJECT DOCUMENTATION INCLUDING, BUT NOT LIMITED TO, PROJECT CHARTERS, PROJECT PLANS, SCHEDULES, STATUS AND PROJECT REPORTS FOR MANAGEMENT, ISSUES/ACTIONS/RISKS LISTS, MEETING AGENDAS, MEETING NOTES, AND PROJECT CLOSURE DOCUMENTATION MAINTAINING CURRENT AND ACCURATE INFORMATION IN THE CAMP DATABASE. EXPEDITING AND COMPLETING HIGH AND MEDIUM PRIORITY PROJECTS FOR ASSIGNED HEALTH PLANS. DETERMINING ROOT CAUSE OF LARGE PROJECT ISSUES TO EDUCATE AND IMPROVE PROVIDER RELATIONS. FACILITATE THE MOVEMENT OF PROJECTS ALONG AS QUICKLY AS POSSIBLE. COMMUNICATING CHANGES IN PROJECT STATUS TO THE APPROPRIATE DEPARTMENTS. WORK WITH BUSINESS CONTROL IN THE TESTING PHASE TO ENSURE NEW CONTRACTS ARE LOADED CORRECTLY IN NETWORXS, AND FACETS SYSTEM..

•Manage the set up and implementation of assigned DeltaCare provider contracts including amendment fee schedule loading and actuarial review.•Handle the billing set up, eligibility collection, database loading, preparation of plan materials such as administrative documents and provider educational materials.•Maintenance and administration of the filing system of executed contracts including archiving of those contracts and updating the status of contracts in the filing system as needed.•Perform compliance analysis of Provider agreements.•Manage flow of contract terminations through the notification process up to the implementation.•Responsible for creating non par provider numbers and working closely with PR reps to fill gap in network based on the number of non contracted requests.•Prepare and maintain documentation/ manuals for use in training or coverage gaps that define operational procedures, describe business requirements and share relevant analysis outcomes with internal and external stakeholders.•Perform quality assurance auditing and reporting to verify accuracy of all data.

Managed/Coordinated The Provider Evaluation And Agreement Implementation Process And The Relationship Between Network Providers And Horizon NJ Health.Developed Provider Targets, Maintain Pertinent Provider Information Relating To Membership, Service Area, Provider Panel, Key Capitated Vendors/Networks, Strengths And Weaknesses, Opportunities, Etc.Coordinated Pertinent Modeling And Evaluates Opportunities And Financial Terms (Fee-For-Service And Capitation) For Both Hospital And Physician Agreements.Assessed Operational And Legal Risks Of Various Contract Provisions.Proposed Alternate Contract Language And Rates As Well As Coordinated Contract Changes Suggested By Horizon NJ Health's Legal, Risk, UR/QA And Other Pertinent Managers.Negotiated Rates and Financial Terms of Managed Care Agreements with Selected Providers.Identified And Recruited New Providers To Fill Specialty Gaps In Medicaid Network.Scheduled and Conducted On-Going Provider Education, Training and Technical Support.Assisted With The Development And Monitoring Of Provider Contracts.Resolved Administrative Problems Affecting Network Providers, And Patients Within Contracted Guidelines For Which The Network Is Responsible.Researched And Coordinated The Resolution Of Provider Claims And Capitation Issues.Assisted In The Development, Distribution And Presentation Of Managed Care Educational And Training Programs To Internal Hospital Personnel And To Employed Physicians And Physician Office Managers.

Investigated and resolved volatile and crucial Georgia Medicaid claim projects and appeals that have not been resolved through normal processing and appeals procedures within the facets claim system.Tracked, and managed global claim issues working with both local and corporate staff to facilitate any corrections or updates needed.Provided education and orientations regarding claim issues and appeal guidelines to providers, and provider reps as needed.Educated and trained Provider Resolution employees on all aspects of claims processing and resolution.Used problem solving skills to identify and correct claim issues.Reviewed and approved second level appeal determinations with CAT team.Worked with regulatory to ensure compliance in regards to investigating, resolving and responding to State of TDI complaints.Researched and documented claim processes, costs and trends associated with Finance and Operational Excellence Projects.Worked with Business control in the testing phase to ensure new contracts were loaded correctly in Networxs.Worked with cost containment to track outstanding projects and identify new issues.

Managed a Large Worker’s Compensation Provider Network Accessed By Summit’s Family Of Companies.Oversaw Network / Recruiting Initiatives For Five Southeastern States, Including GA, TN, NC, SC, And KY.Initiated / Maintained Progressive Working Relationships With Network Providers And Independently Identified Individual Physicians And Medical Groups; Identified Areas To Improve Provider Service Levels Within Operating Budget.Identified Provider Educational Opportunities And Delivered Appropriate Training On All Products.Coordinated, Created, and Disseminated Provider Training Materials; Delivered Training to Doctors, Office Staff, In-Service Assignments on The Official Disability Guidelines, And Special Projects.Managed Ongoing Activity Relative To Provider Concerns / Issues; Anticipates Potential Provider Issues And Needs.Prepared And Facilitated Operational Meetings With Internal And External Customers.Determined Network Inadequacy And Recruited New Providers For PPO Network Penetration Through State Mandated Audits; Negotiated Contracts With Physicians, Hospitals, And Ancillary Services.Provided Quarterly And Annual Outcome Studies To QM Committee, As Well As Weekly Reporting To Network Team In Conjunction With Weekly And Monthly Phone Conferences.

ESTABLISHED AND MAINTAINED POSITIVE RELATIONSHIPS WITH ASSIGNED PROVIDER GROUPS, THE OBJECTIVE BEING TO SERVE AS LIAISON BETWEEN BLUE CROSS AND PROVIDER NETWORK.ASSISTED WITH CREDENTIALING AND RECREDENTIALING OF NEW AND EXISTING CONTRACTED PROVIDERS.COORDINATED / IMPLEMENTED EDUCATION AL AND CONTRACTING EFFORTS WITH HOSPITALS, DME VENDORS, AMBULATORY SURGICAL CENTERS, AND PHYSICIANS TO SUPPORT SAVANNAH / AUGUSTA MARKET EXPANSION.MANAGED PROVIDER OUTREACH ACTIVITIES IN A DEFINED AREA, UTILIZED ALL INTERNAL RESOURCES BY MAINTAINING A CLOSE WORKING RELATIONSHIP WITH APPROPRIATE INTERNAL DEPARTMENTS.PROVIDED FEE SCHEDULES, NEGOTIATED CONTRACTS, ASSISTED WITH RECRUITMENT EFFORTS; HANDLED NETWORK PARTICIPATION APPLICATION REQUESTS, AS WELL AS ANY DEMOGRAPHIC CHANGES OR UPDATES REQUESTED BY PROVIDER.

DEVELOPED AND MAINTAINED POSITIVE RELATIONS WITH HEALTHCARE PROVIDERS, PRACTICE ADMINISTRATORS, OFFICE MANAGERS, BROKERS, AND AGENTS WITHIN A LOCAL ASSIGNED TERRITORY.RESEARCHED AND RESOLVED MEMBER GRIEVANCES, PROVIDER COMPLAINTS, AND APPEALS.MAINTAINED INVENTORY OF APPEALS FOR MONTHLY REPORTING IN ACCESS DATABASE.TEAMED WITH UM TO COLLECT DATA FOR GRIEVANCES AND APPEAL DECISIONS.PREPARED MATERIAL FOR NEWLY CREDENTIALED PROVIDERS TO SEND WELCOME PACKETS.REVIEWED INITIAL NON-CREDENTIALED AND CREDENTIALED APPLICATION.ASSISTED CREDENTIALING AREA IN OBTAINING ADDITIONAL INFORMATION AS NEEDED

Reviews and adjudicates health related claims based on policy provisions and established guidelinesRequests additional information from members and providers as neededInitiates and completes claim investigations when indicated including pre-existing conditions, accidents, medical necessity and appropriateness, eligibility and coordination of benefitsDocuments fully claims referred to senior staff for review and determinationMaintains company production and quality standards of 95% statistical accuracy and 99% payment accuracyParticipates in training