Network Payor Relations & Compliance Specialist - Full time - Detroit

GENERAL SUMMARY:
Under general supervision, performs provider enrollment and compliance functions within a Clinically Integrated Network (Network). Key duties include data management, ensuring providers meet standards and regulations, processing Network credentialing applications, maintaining relationships between payors, clinics, and providers, and verifying compliance with contractual obligations. The role performs further credentialing functions including resolving claims issues, assisting with onboarding new practices, and conducting audits to ensure compliance. Responsible for creating communication materials, maintaining up-to-date payor information, and providing patient support for Medicaid redetermination and enrollment.

PRINCIPLE DUTIES AND RESPONSIBILITIES:
* Ensures providers are enrolled in the Network according to current standards and regulations and maintains stringent compliance with payors.
* Facilitates preparation for the Network Credentialing Committee, reviewing files for accuracy and completion. Works with the Committee Chair to perform the administrative review process and attain approval sign-off.
* Responsible for meeting any contractual obligations outlined within all delegated credentialing agreements held by the Network.
* Serves as the point of contact for Network practices to address claims issues with Network payors by troubleshooting on behalf of the practice and working with the payor to resolve.
* Provides enrollment assistance/support to Network provider members for nondelegated health plans as needed.
* Supports new practice onboarding by providing support pertaining to credentialing, execution of participation agreements, health plan enrollment, fee schedules, and ensure smooth transition of support to Network practice transformation team.
* Performs data entry, collection, and analysis to complete tasks supporting provider primary source verifications and enrollment processes.
* Responsible for completing various audit activities to ensure contractual compliance and satisfying NCQA standards. Audit activities include annual audits which are initiated by delegated payors, regular auditing of primary source verifications (PSV), and conducting annual audits of sub-delegate groups to the Network, such as the Henry Ford Health Central Verification Office.
* Ensures Network practice compliance and contractual obligations through comprehensive and manual validation of information (i.e., confirmation of practice hours). Performs tasks to support accurate records and roster management including:
o Network provider membership profiles within Network's data management tool.
o Updates external provider alignment tools used to align physicians to a particular group for purposes of their quality rewards program.
o Maintains accurate record of specialist referral information, provider panel status by product line, and Network's criteria for incentive eligibility.
o Supports Network patient alignment including but not limited to member transfer submissions and resolution tracking.
o Responsible for accurate and prompt submission of the Network provider roster to each payor using payor-specific formatting. Additional ad-hoc requests require creation of provider rosters, using variety of data platforms, for multiple use cases.
o Maintains the Network provider roster for the Accountable Care Organization (ACO) contract including all provider additions, terminations, or changes to the ACO contract.
o Maintains current payor information, including fee schedules and policies, within the Network's SharePoint website.
o Through ongoing partnerships and collaboration with non-delegated health plans, ensures all appropriate providers are accurately aligned to Network.
* Performs outreach to patients due for Medicaid redetermination, provides education to patients on process, answers questions, assists with online forms, and provides enrollment support.
* Follows the procedures defined by Network's patient compliant policy including reviewing patient concerns with Network administrative leadership and Network medical directors.
* Supports the Network communications and education through creating a monthly payor newsletter capturing updates from Network contracted health plans including coding, billing, prior authorizations, upcoming webinars, operations, and provides CPT coding and billing education to Network members.
* Performs ongoing evaluation, maintenance, and execution of the Network participation agreements. Maintains all policies and procedures related to Network provider affairs and delegated credentialing.
* Additional responsibilities including, but not limited to:
o Maintenance of the Network Behavioral Health Provider Directory.
o Attending the Network Credentialing Committee as requested by leadership.
o Submission of Blue Care Network's Medical Care Group affiliation form for Network independent providers.
o Payor outreach as needed on behalf of providers.