• Provider Account Specialist

    Job Locations US-NC-Gastonia | US-NC-Hickory | US-NC-Statesville
    Posted Date 2 weeks ago(11/5/2018 3:11 PM)
    Job ID
    # of Openings
    Community and Social Services
  • Overview

    Excellent Benefits Package!!!

    Location: Gastonia, Hickory or Statesville

    Projected Hiring Range: Depending on Experience


    Closing Date: 11/19/2018 by 4 PM


    Primary Purpose of Position: This position assists in the credentialing, development and management of the provider network for consumers who have been identified as having mental health, substance use or intellectual developmental disability needs. The Provider Network Account Specialist is responsible for developing, maintaining and servicing high quality, marketable and satisfied provider network within an assigned geographic area. This position is expected to build and sustain strong working relationships with cross functional departments and assigned Providers. The Provider Account Specialist helps assigned Providers operate successfully within our healthcare delivery model by providing strategic education on the special needs of the enrollees, comprehensive understanding of the contract and the PNS plans quality initiatives.




    Role and Responsibilities:

    A Provider Network Account Specialist primary duties may be one or more of the following:

    • Educating the providers to ensure they understand the contract and the Medicaid initiatives regarding this population and the contract requirements of the PNS.
    • Educating the providers to the mandated best practices for their provider type and the quality measures of the PNS.
    • Coordinates with other PNS internal departments to resolve questions or issues regarding prior authorizations, claims submission or payment issues.
    • Conducts new provider orientations and ongoing education to providers and their staffs regarding claims, payments, ·eligibility, utilization management or any other questions impacting provider performance,
    • Conducts provider meetings to share and discuss issues of concern, troubleshoots for issue resolution, and implements an escalation process for discrepancies.
    • Handles or ensures appropriate scheduling, agenda, materials, location, of provider meetings as needed.
    • Collaborates with Credentialing Department to ensure provider data is correct and include any needed updates.
    • Assists providers to obtain and complete Provider Change Forms as needed. Provides information and participates in management meetings as requested.
    • Enhance account relationships by investigating, documenting, and resolving provider matters and effectively handling and responding to account changes and correspondence.
    • Provide information and status updates for providers regarding incentive agreements and how to maximize their performance.
    • Regularly meets with other internal departments to create, revise and adjust strategy for assigned provider groups to meet overall performance goal.
    • Assists with development and implementation of contracts for agencies and licensed independent practitioners.
    • Reviews and Signs-off on Provider Invoices.
    • Chair, Co-Chair, and Participate in internal and external committees.
    • Capable of working with all levels of the organization including Executive Leadership Team, Departmental Directors, and Managers to assist with problem resolution.
    • Active Participation in Opiate Use Disorder committees and initiatives
    • Monitoring and Oversight of the NC Super-measures with providers.
    • Work with finance to track and monitor utilization of all funding mechanisms
    • Technical Assistance-Assisting providers as needed with our internal systems-authorization, claims, alpha issues.
    • Serves as a resource to other departments within the LME/MCO on provider-related issues.
    • Coordinate meetings with Providers and Internal staff
    • Participates in Provider Forums as requested and provide technical support and assistance to Provider Councils as needed
    • Participate in internal workgroups that involve existing providers.
    • Assist with Identifying & developing provider training to meet provider needs.
    • Assigned to DOJ/TCL initiatives.
    • Development of Policy & Procedure, and notifications associated with Contract Performance monitoring.
    • Review and Approval of HCBS assessments
    • Contract Performance Monitoring
    • Responsible for pulling multiple reports from ALPHA/Report Manager/ACORN to share with providers for them to improve upon; such as, 1st responder report, NC TOPPS, ED admissions.
    • Participation in internal and external committees.


    Knowledge, Skills and Abilities:

    • Considerable knowledge of the laws, regulations and policies that govern the program
    • Exceptional interpersonal and communication skills
    • Strong problem solving, negotiation, arbitration, and conflict resolution skills
    • Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint)
    • Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws, rules and regulations to various situations; to apply regulations and policies for maintenance of consumer medical records, personnel records, and facility licensure requirements
    • Ability to make prompt independent decisions based upon relevant facts
    • Ability to establish rapport and maintain effective working relationships
    • Ability to act with tact and diplomacy in all situations
    • Ability to maintain strict confidentiality in all areas of work



    Education/Experience Required:

    Bachelor’s Degree in healthcare administration, business administration, accounting, finance, or human services and five (5) years of experience in provider network management, health care insurance or other MH/SU/IDD healthcare delivery setting. Must have ability to travel..


    Education/Experience Preferred:

    Master’s Degree in Business Administration or Human Services and two years’ experience in a clinical environment. Clinical licensure preferred.


    Licensure/Certification Requirements:



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