Payer Relations Specialist

Jefferson City, MO - USA

Monthly Salary: Not Disclosed

Posted on: 3 days ago

Vacancies: 1 Vacancy

Job Summary

Company:Missouri Primary Care Association MPCA
Job Title:Payer Relations Specialist
Job Classification:Exempt Full-Time
Work Schedule:Monday through Friday
Reporting Structure: Vice President ofPayer Relations
Eligible for Remote:No
Location:Jefferson City MO on-site

Primary Accountability:
Assists Vice President of Payer Relations with (VPPR) designing and implementing programs policies and procedures to oversee and solidify all Credentialing requirements and relationship management with health centers and MCO payer contacts. Maintains a lead role in day-to-day delegated Credentialing functions process improvement and internal staff audits and maintains efficiencies and overall operational compliance.

Major Duties:

Accurate and timely processing of initial and re-credential applications meeting verification requirements and standards for MHP to maintain delegated credentialing authority with the MCOs.
Maintain strong relationships with all payers and health center staff. Establish regular meetings as needed with payers to review and resolve any operational provider data discrepancies or payment issues. Remain visible and accessible to both FQHCs and payer staff.
Review and analyze health center member presented claims and provider load discrepancies to identify root cause issues as site billing payer set up or contract interpretation discrepancies and understand and remain knowledgeable of contract payment terms with ability to identify payment/procedural processing errors and follow up on any discrepancies.
Collaborate with payer provider relations/claims staff to resolve any operational or procedural issues/patterns with payers or health centers. Coordinate with health center staff to correct any issues.
Distribute best practices operational information and updates across the MHP network.
Collaborate closely with Missouri Health Plus team to support patient engagement activities and achievement of various incentives and goals.
Ensures enrollment access for MHP team is maintained with vendor/source verification electronic sites and portals.
Support Contracting team during payer negotiations by identifying key areas of payment or procedural problems in an effort to change terms to avoid future recurrences.
Provide knowledge and support of the delegated credentialing process for the organization.
Lead the credentialing committee on related processes have a broad knowledge of Payer and State/Federal regulations including Medicaid and Medicare including provider licensure and certification ongoing monitoring as identified in policy and processes.
Facilitate and conduct required monthly Credentialing Committee meetings with agenda and minutes.
Support annual payer delegation audits including key input in the review of audit results against policies and procedures for process improvement.
Support routine Joint Operations Meetings (JOCs) with payers.
Lead and maintain functionality and processes of credentialing database to support ongoing functions monitoring and requirements of the delegated credentialing process.
Identify payer policy and procedure updates that impact FQHCs and act as a liaison to relay the relevant information timely.

Qualifications:

High school diploma or equivalent required. Bachelors Degree preferred.
One to three (1-3) years experience within a medical dental or behavioral health practice.
One to three (1-3) years experience with provider credentialing highly preferred.
Experience with Missouri based Federally Qualified Health Centers (FQHC) Community Mental Health Center (CMHC) or outpatient primary care practice highly preferred.
Experience using CAQH Solutions ProView preferred.
Familiarity with NCQA and delegated credentialing process preferred.
Proficiency in all Microsoft Office products required.
Strong interpersonal communication skills with the ability to effectively communicate both written and verbal in a professional manner that supports the ability to establish and maintain effective working relationships across all levels of MPCA and external stakeholders.
Strong organizational skills the ability to prioritize and the ability to coordinate multiple projects with minimal supervision.
Ability to work in team settings to show flexibility and versatility.
Ability to learn additional software applications.
Ability to self-motivate and thrive in a complex and rapidly changing environment.
Ability to work with strict confidentiality requirements as well as utilize good judgment in the preparation and distribution of confidential information.

Physical Demands:

Ability to sit stand walk reach and use hands and fingers for extended periods of time.
Performing physical activities which require considerable use of your arms and legs for moving your entire body such as climbing lifting balancing walking bending kneeling crawling stooping and handing of materials.
Ability to read computer screens mail e-mail and talk on the phone.
Ability to unpack and move supplies up to thirty (30) pounds.
Ability to drive an automobile and possess a valid drivers license.

Work Environment:

Professional and deadline-oriented environment in an office setting.
Interaction with internal and external customers.
Job duties will be performed onsite at the Jefferson City MO location.

Travel:

Travel will be expected in and outside of Missouri.

Additional Duties:
Additional duties and responsibilities may be added to this job description at any time. The job description does not state or imply that these are the only activities to be performed by the employee(s) holding this position. Employees are required to follow any other job-related instructions and to perform any other job-related responsibilities as requested by leadership.

Required Experience:

Company:Missouri Primary Care Association MPCAJob Title:Payer Relations SpecialistJob Classification:Exempt Full-TimeWork Schedule:Monday through FridayReporting Structure: Vice President ofPayer RelationsEligible for Remote:NoLocation:Jefferson City MO on-sitePrimary Accountability:Assists Vice Pre...

Accurate and timely processing of initial and re-credential applications meeting verification requirements and standards for MHP to maintain delegated credentialing authority with the MCOs.
Maintain strong relationships with all payers and health center staff. Establish regular meetings as needed with payers to review and resolve any operational provider data discrepancies or payment issues. Remain visible and accessible to both FQHCs and payer staff.
Review and analyze health center member presented claims and provider load discrepancies to identify root cause issues as site billing payer set up or contract interpretation discrepancies and understand and remain knowledgeable of contract payment terms with ability to identify payment/procedural processing errors and follow up on any discrepancies.
Collaborate with payer provider relations/claims staff to resolve any operational or procedural issues/patterns with payers or health centers. Coordinate with health center staff to correct any issues.
Distribute best practices operational information and updates across the MHP network.
Collaborate closely with Missouri Health Plus team to support patient engagement activities and achievement of various incentives and goals.
Ensures enrollment access for MHP team is maintained with vendor/source verification electronic sites and portals.
Support Contracting team during payer negotiations by identifying key areas of payment or procedural problems in an effort to change terms to avoid future recurrences.
Provide knowledge and support of the delegated credentialing process for the organization.
Lead the credentialing committee on related processes have a broad knowledge of Payer and State/Federal regulations including Medicaid and Medicare including provider licensure and certification ongoing monitoring as identified in policy and processes.
Facilitate and conduct required monthly Credentialing Committee meetings with agenda and minutes.
Support annual payer delegation audits including key input in the review of audit results against policies and procedures for process improvement.
Support routine Joint Operations Meetings (JOCs) with payers.
Lead and maintain functionality and processes of credentialing database to support ongoing functions monitoring and requirements of the delegated credentialing process.
Identify payer policy and procedure updates that impact FQHCs and act as a liaison to relay the relevant information timely.

Qualifications:

High school diploma or equivalent required. Bachelors Degree preferred.
One to three (1-3) years experience within a medical dental or behavioral health practice.
One to three (1-3) years experience with provider credentialing highly preferred.
Experience with Missouri based Federally Qualified Health Centers (FQHC) Community Mental Health Center (CMHC) or outpatient primary care practice highly preferred.
Experience using CAQH Solutions ProView preferred.
Familiarity with NCQA and delegated credentialing process preferred.
Proficiency in all Microsoft Office products required.
Strong interpersonal communication skills with the ability to effectively communicate both written and verbal in a professional manner that supports the ability to establish and maintain effective working relationships across all levels of MPCA and external stakeholders.
Strong organizational skills the ability to prioritize and the ability to coordinate multiple projects with minimal supervision.
Ability to work in team settings to show flexibility and versatility.
Ability to learn additional software applications.
Ability to self-motivate and thrive in a complex and rapidly changing environment.
Ability to work with strict confidentiality requirements as well as utilize good judgment in the preparation and distribution of confidential information.

Physical Demands:

Ability to sit stand walk reach and use hands and fingers for extended periods of time.
Performing physical activities which require considerable use of your arms and legs for moving your entire body such as climbing lifting balancing walking bending kneeling crawling stooping and handing of materials.
Ability to read computer screens mail e-mail and talk on the phone.
Ability to unpack and move supplies up to thirty (30) pounds.
Ability to drive an automobile and possess a valid drivers license.

Work Environment:

Professional and deadline-oriented environment in an office setting.
Interaction with internal and external customers.
Job duties will be performed onsite at the Jefferson City MO location.

Travel:

Travel will be expected in and outside of Missouri.

Required Experience:

Key Skills

Customer Service
CFA
Ethernet
Fiber
Anesthesia

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About Company

HR Partners

Norton County Hospital is a 25-bed critical access hospital and Level IV trauma center, and along with the Norton Medical Clinic, provides medical services for residents in Norton County and surrounding northwest Kansas and southwest Nebraska communities.

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