Job Brief

Must Live In/Near: Cincinnati, OH. Medicaid Manage Care related credentialing, claims, provider training/education, healthcare and provider services experience.

Responsibilities:

• The Provider Relations/Services Account Executive I is responsible for building, nurturing and maintaining positive working relationships between Plan and its contracted providers.
• Assigned provider accounts may include single or multiple practices in single or multiple locations, integrated delivery systems or other provider organizations.
• AE I maintains in depth understanding of Plan’s contracts and provider performance and needs, identifying, developing and conducting relevant and tailored provider orientation sessions, making educational visits and working to resolve provider issues.
• Responsible for monitoring and managing provider network by assuring appropriate access to services throughout the Plan’s territory in keeping w/ State and Federal contact mandates for all products.
• Identifies, contacts and actively solicits qualified providers to participate in Plan at new and existing service areas and products, assuring financial integrity of the Plan is maintained and contract management requirements are adhered to, including language, terms and reimbursement requirements.
• Maintains complete understanding of Plan reports and metrics and uses them to evaluate the performance of assigned providers/practices/facilities, determining, communicating and implementing plans for providers to improve performance and measuring ongoing performance.
• Uses data to develop and implement methods to improve relationship.
• Assists in corrective actions required up to and including termination, following Plan policies and procedures.
• Supports the Quality Management department with the credentialing and re-credentialing processes, investigation of member complains and any potential quality issues.
• Maintains a functional working knowledge of Facets, including the provider database and routinely relays information about additions, deletions or corrections to the Provider Maintenance Department.
• Maintains and delivers accurate, timely activity and metric reports as required.
• Identifies and maintains strong partnerships with appropriate internal resources and stakeholders.

Education/ Experience:

• Bachelor's Degree.
• 1 to 3 years experience in a Provider Services position working with providers.
• 3 to 5 years experience in the managed care/health insurance industry.
• Medicaid experience preferred.
• Demonstrated strength in working independently, establishing influential relationships internally and externally, meeting and training facilitation skills, priority setting and problem solving skills.
• Must reside in or nearby Cincinnati,Ohio.

Key words: Must have credentialing, claims, provider training/education, healthcare and provider services experience.