MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries in Ohio. We’re dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage. We rely on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, provider relations and more.
The Provider Relations & Network Manager is responsible for a full range of provider relations and service interactions in MediGold's new Boise, ID marketing, including: contracting and recruitment, issue resolution and escalations, strategy development and execution, education, and retaining MediGold Contracted Providers. This position serves as the primary point of contact for the Providers and will require extensive relationship building, driving the resolution of complex issues, and MediGold brand building. The individual will also assist the Director for Provider Contracting and Network Development to develop provider collaborations that ensure network growth and quality/efficiency targets.
Recruit providers to build a cost effective and high quality provider network within MediGold guidelines.
Serve as the MediGold point of contact within the Provider network; Act as the MediGold Subject Matter Expert and brand ambassador.
Addresses customer complaints by directly handling the issue, working with the correct department(s) to resolve, or escalating as required.
Engage Providers to develop, coordinate, and lead training and distribution of materials.
Proactively drive communications with Providers via telephone/email and onsite visits.
Collaborates with the Director - Provider Contracting and Network Development to develop communication goals, strategies, and plans.
Negotiates provider contracts within MediGold guidelines and financial standards.
Collaborates with the Managers of Member and Provider Communications to oversee the completion of all provider communication content and materials.
Manages and works with other internal partners to facilitate provider Joint Operating Committee (JOC) Meetings.
Develops, implements, and manages policies, and procedures as assigned.
Assists Director and/or Sr. Director with the Medical Delivery Systems budget.
Manages successful implementation of provider contracts, including interpretation of payment and reimbursement terms.
Maintains excellent working relationships with MEDIGOLD's provider network, internal department management, other business partners, Health System related entities.
Exhibits a professional appearance and demeanor.
Travel to regional client locations and corporate office as required.
Use of personal vehicle for Provider visits required.
All other duties as assigned.
Education: Bachelor's degree in Healthcare Administration, Finance, related field or equivalent experience.
Experience: Minimum five years of experience with a Health Plan or Health Provider.
contracting and network development experience highly preferred
Knowledge of physician claims coding and Provider reimbursement payment methodologies; Ability to interpret Provider contracts
Willingness to be the point of contact for the MediGold brand within the Provider network
Establish and maintain relationships with Providers to ensure quality and satisfaction of services provided
Capacity to address complex problems including claims issues and customer service complaints; work with other departments to achieve resolution of the issues
Demonstrated ability to identify areas of opportunity within Provider networks for improving overall efficiency and quality
Working knowledge of protocols and procedures of Centers For Medicare and Medicaid Services
Proven ability to work effectively with internal and external multi-disciplinary teams across all levels of the organization
Proven track record of managing multiple priorities and executing tasks within tight timeframes
Experience in identifying and executing process improvement needs
Must possess a high degree of motivation, initiative, and organization ability
Valid driver's license
Global Recruitment and Talent Acquisition Services, LLC -Grtas, LLC is a Global Professional Services Firm - Our goal is to provide both our candidates and our Clients an efficient and streamline Talent Acquisition experience.