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Provider Relations Specialist at Capital District Physicians' Health Plan, Inc

Posted in Other 30+ days ago.

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Type: Full Time
Location: Albany, New York

Job Description:

For more than 30 years, CDPHP has been providing outstanding health care coverage in the Capital Region of New York and beyond. Based in Albany, NY, the physician-guided not-for-profit offers plans in 24 counties. CDPHP cares deeply about the health and well-being of its members as well as its employees. The company values integrity, diversity, and innovation, and its corporate culture supports those values wholeheartedly. At CDPHP, the employees have a voice and are encouraged to make an impact at both the company and community levels through engagement and volunteer opportunities. CDPHP invests in employees who share these values and invites you to be a part of that experience.

The Provider Relations Specialist is responsible for managing the relationship between the provider and CDPHP. The Provider Relations Specialist will be the lead in providing effective support and education to their assigned provider community. The Provider Relations Specialist is the key liaison for all operational aspects of the relationship including coordination with CDPHP provider facing initiatives and activities. The incumbent is responsible for successfully administering, servicing, monitoring and growing the strategic relationships with provider. The Provider Relations Specialist will take a proactive and innovative approach to the provider relationship, track all high priority, and re-occurring issues, key provider and office related information. This position will assure resolution of service and executive issues and engage in service recovery activities if a provider relationship is damaged.


* Associates degree required. 3 years relevant experience may be substituted for degree.

* Minimum of 7 years direct provider business-to-business relationship management experience in health care administration preferred.

* Experience with business analysis, risk mitigation, relationship management and new business process enterprise implementation with data metrics collection and reporting preferred.

* Experience in hospital, ancillary and physician claims payment and other system pricing details required.

* Experience working with clinical personnel in supporting clinical initiatives in quality metrics (HEDIS, QARR, NCQA, etc), health care coding, state and federal regulations and reimbursement methodologies required.

* Working knowledge of provider reimbursement and payment methodologies is required.

* Demonstrated medical and facility coding knowledge, including UB04, CPT, ICD-9, and HCPCS (and future successors i.e. ICD10) is required. CPC or CPC-H preferred. Experience in health insurance claims and appeal processing with ability to apply Coordination of Benefits and medical policy is required.

* Must be able to effectively coordinate across, up, and down within the organization to resolve provider issues and implement strategic initiatives.

* Must have strong analytical skills and be an excellent strategic thinker.

* Strong detailed managed care product knowledge across all CDPHP lines of business.

* Demonstrated ability to successfully and positively interact with external provider senior financial and operations management, physicians and business offices.

* Must have excellent verbal and written communication, interpersonal and organizational skills.

* Robust analytical skill in database management through experience with Excel and/or Access databases.

* Demonstrated ability to lead processes and obtain desired outcomes on time.

* Demonstrated ability to manage and shape strategic priorities to meet operational needs.

* Proficiency in Microsoft Word, Excel, PowerPoint and Access.

* Ability to adapt to regional travel.

* Must possess thorough knowledge of contracting structures and payment methodologies.

* Comprehensive understanding of Commercial, Medicare and Medicaid reimbursement methodologies and rates required.

* Some overnight travel may be required.

As an Equal Opportunity / Affirmative Action Employer, CDPHP will not discriminate in its employment practices due to an applicant s race, color, creed, religion, sex (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity or expression, transgender status, age, national origin, marital status, citizenship, physical and mental disability, criminal record, genetic information, predisposition or carrier status, status with respect to receiving public assistance, domestic violence victim status, a disabled, special, recently separated, active duty wartime, campaign badge, Armed Forces service medal veteran, or any other characteristics protected under applicable law.