Provider Network Operations (PNO) Field Representative
Under the general direction of the Provider Network Operations (PNO) – Contracts Team Supervisor, the PNO Field Representative’s primary function is to develop relationships and act as a liaison to assist providers in all aspects of their participation within the provider network of their assigned MedPOINT Management (MPM) client(s). The PNO Field Representative educates providers (Primary Care Physicians (PCPs), Specialists and Ancillary) and their office staff on basic client operation/service delivery protocols, ensures that providers are in compliance with Health Plan, State and Federal government regulations, responds to and effectively resolves concerns and issues of their provider network documenting resolution and initiating additional training needs and communicating observations to Supervisor and Management Team. The candidate will possess comprehensive knowledge of the authorizations and claims functions, credentialing requirements, the application and contracting process, and other topics of general and specific interest to the provider.
Duties and Responsibilities
- Conduct New Provider and Staff Orientations and continued education of existing providers to ensure IPA programs, initiatives and requirements (i.e. coordination of care, credentialing, P4P, Encounters, etc.) are being effectively communicated and followed by the provider network. Also, to ensure provider is effectively utilizing company tools (i.e. MPM Portal and online compliance training) available to them.
- Assist with implementation of new policies and procedures, and the development and implementation of provider training programs.
- Distribute, maintain, and ensure accuracy of IPA provider onboarding materials, monthly updates, and bulletins to keep provider offices informed of all changes.
- Proactively identify provider needs and advise Supervisor and Management team so that action can be taken to address the needs prior to provider becoming unsatisfied/problematic.
- Perform oversight of their assigned networks to ensure network provider deficiencies are being met and working closely with their client specific assigned Contract Specialist(s), Contract Coordinator(s), and Medical Management counterparts to ensure network needs/changes are being effectively addressed and communicated both internally and externally.
- Maintain and update the appropriate site visit and claims resolution logs and department tools with current information.
- Responsible for the coordination and receipt of credentialing applications and provider updated correspondence to ensure the department has obtained proper signatures and documentation to effectively process newly recruited providers that are part of existing/contracted provider groups.
- Assist with the resolution of provider grievances and appeals in accordance with contractual requirements and corporate policy.
- Engage in daily interaction with assigned providers (PCPs, Specialist or Ancillary providers). Engagement may be telephonic, via email and/or in person site visits.
- Ensure contract compliance and adherence to DMHC, DHCS, CMS and other regulatory agencies as required by company policy and contracting HMOs.
- Coordinates, attends, and participate in various meeting as assigned.
- Act as Internal network liaison for Database, Compliance, Claims, Member Services, Utilization Management, and Quality Management Departments.
- Attend the quarterly Joint Operations Meetings, where applicable, with contracted providers and office staff.
- Establish a positive work environment that encourages participation in process improvement and commitment to department/company success
- Understand and follow the Employee Handbook policies and procedures.
- Ensure HIPAA compliance is observed/performed at all times.
- Perform other duties/assignments as needed.
Skills and Abilities
- Establish, maintain, and foster collaborative relationships through both verbal and written communication
- Excellent active listening and critical thinking skills
- Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers
- Ability to develop and present training materials to an audience
- Ability to multi-task, exercise excellent time management, and meet multiple deadlines
- Ability to maintain confidentiality and appropriately share information on a need to know basis
- Excellent attention to detail and ability to document information accurately
- Self-motivated with strong organizational, multi-tasking, planning, and follow up skills
- Ability to accept instructions and work independently in the completions of goals and assignments
- Ability to quickly learn and use new software tools
- Ability to provide and receive constructive job and/or industry related feedback
- Willingness take on and lead projects outside the normal scope of the job description
- Strong and consistent customer service acumen with the ability to resolve complaints and concerns
- Demonstrate commitment to the organization’s core values
Minimum Job Requirements:
- Bachelor’s degree in healthcare, human services or related field preferred
- 2+ years Managed Care or Healthcare experience
- Must have reliable transportation
- EZ-CAP knowledge preferred
- Proficient in Microsoft Office Suite (Word, Excel, PowerPoint, Outlook)
- Substantive knowledge of the HMO marketplace including Medi-Cal, Commercial, and Medicare