Contracts and Provider Relations Assistant

Job title

Contracts & Provider Relations Assistant

Department

Provider Relations

Reports to

Contracts & Provider Relations Manager

Vice President

Medical Management

Updated

February 2025

Nature of Work in this Position:The primary responsibility of this position is to assist in the coordination and maintenance of the organization’s provider network contracting, credentialing, development, and maintenance tasks as well as the company’s provider, government and community relation activities; acts as company liaison with various entities.

Illustrative Examples of Work:

• Coordinates the company’s provider recruitment and contracting activities and provide orientation to new providers.
• Assists in the development and execution of provider evaluation; credentialing and re-credentialing programs, both short and long term, to ensure the availability of quality health care for members.
• Assists in provider negotiation, research, and establishment of fee schedule to ensure appropriate compensation of providers.
• Collect, collate, analyze and reports provider reimbursement and utilization data for use in contract negotiations and policy creation.
• Conducts provider education on company policies and lead proactive orientation seminars with providers and provider groups.
• Maintains effective control of the member-provider-insurance referral system and the correct implementation of contracts / policies.
• Develop and maintains a provider file, database, directory, and provider relations manual.
• Ensures that provider files, including but not limited to, Provider Directory, Provider Manual, Provider Newsletters, Provider contracts/fees/notices, Provider cost estimates for members, Provider information updates or attestation requests and Provider network status, are released on time and made available in compliance with applicable provider contracts and relevant Federal and State law.
• Ensures compliance with Plan Accreditation requirements for Provider Network Credentialing
• Facilitates system fee configuration and testing
• Maintains close coordination with the UM Informed Choice, Health Management, Customer Care, Claims, Actuarial and Underwriting, and Marketing & Sales Departments in enhancing provider and customer satisfaction.
• Releases external and internal communication regarding provider contract and policy issues.
• Participates in various standing and ad hoc committees including Company’s Provider Credentialing Committee and Appeals Committee.
• Provides support to the Marketing & Sales department in all public marketing campaigns via review of printed materials, event planning, coordination and participation.
• Keeps current on Federal and local legislation / regulations affecting health insurance.
• Ensures timely handling of provider complaints, grievances, disputes, appeals and requests for reconciliation.
• Prepares activity report and maintain the confidentiality of information processed.
• Performs related duties as required. (Related duties are duties that may not be specifically listed in the class specification or position description, but that are within the general occupational series and responsibility level typically associated with the employee’s class of work.)

Knowledge / Skills / Abilities:

• Significant organizational skills.
• Strong verbal and written communication.
• Attention to detail and quality focused.
• Ability to multi-task and manage time efficiently.
• Ability to read, analyze and interpret technical journals, worksheets, financial reports, and legal documents (e.g. contracts).
• Ability to respond to common inquiries, complaints from providers, customers, outside agencies, or members of the health care community.
• Ability to construct letters, reports that conform to prescribed style and format.
• Ability to conduct effective presentations to management, provider groups and customers.
• Ability to work effectively with employees and the public.
• Ability to work under the stress of meeting many requests from various departments and individuals, sometimes with conflicting deadlines.
• Knowledge of Medicare and HIPAA rules and regulations.

Minimum Experience and Training:

Any combination of education and experience providing the required skill and knowledge for successful performance would be qualifying. Typical qualifications would be equivalent to:

• A Bachelor’s or Associates degree in Math, Statistics or related field or equivalent experience;
• Minimum of two (2) years’ experience in health insurance is preferred;
• Proficient in the use of Microsoft Office (Excel, Word, PowerPoint, Outlook); and
• Computer literate (Windows).

Note: This job specification should not be construed to imply that these requirements are the exclusive standards of the position. Incumbents will follow any other instructions, and perform any other related duties, as may be required by their supervisor.

This job entails access to PHI / ePHI data. Any personally identifiable health information, including genetic and demographic data, collected from an individual by a covered entity. This includes information related to an individual's past, present, or future physical or mental health, healthcare provision, or payment. PHI includes information like the patient's name or other identifiable data. It excludes information in education records and employment records held by a covered entity. PHI also excludes information related to individuals who have been deceased for more than 50 years. The hired individual is expected to maintain policies and procedures to ensure compliance with HIPPAA regulations in handling PHI/ePHI data.

Job Type: Full-time

Pay: $12.53 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee discount
• Health insurance
• Life insurance
• Paid time off

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Supplemental Pay:

• Bonus opportunities

Work Location: In person