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Provider Relations Rep II
Provider Relations Rep IIModa Health • Portland, Texas, USA
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Provider Relations Rep II

Provider Relations Rep II

Moda Health • Portland, Texas, USA
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Lets do great things together!

About Moda

Founded in Oregon in 1955 Moda is proud to be a company of real people committed to quality. Today like then were focused on building a better future for healthcare. That starts by offering outstanding coverage to our members compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places together. Moda values diversity and inclusion in our workplace. We aim to demonstrate our commitment to diversity through all our business practices and invite applications from candidates that share our commitment to this diversity. Our diverse experiences and perspectives help us become a stronger organization. Lets be better together.

Position Summary

Provide exceptional customer service to contracted providers by being the liaison between the contracted provider and the Health Plan. The Provider Relations Representative is responsible for presenting promoting and resolving concerns and issues brought forward by the providers or the Health Plan. This is a FT WFH role.

Pay Range

$53596.39- $67000.66 salary (depending on experience) This role may be classified as hourly (non-exempt) depending on the applicants location. Actual pay is based on qualifications. Applicants who do not exceed the minimum qualifications will only be eligible for the low end of the pay range.

Please fill out an application on our company page linked below to be considered for this position.

Dental Vision Pharmacy Life & Disability

  • 401K- Matching
  • FSA
  • Employee Assistance Program
  • PTO and Company Paid Holidays

Required Skills Experience & Education :

  • College degree or equivalent work experience in the health insurance industry
  • 2-4 years experience as a Provider Relations Rep with a Health Plan or 2-4 years experience as a Provider Relations Rep I with Moda.
  • Strong facilitation skills with an ability to run provider meetings with prioritized specific topic agendas reflecting entire provider support.
  • Strong relationship building skills.
  • Demonstrated strong verbal written and interpersonal communication skills.
  • Possess analytical problem-solving and attention-to-detail skills.
  • Knowledge of medical insurance reimbursement methodologies including but not limited to DRG and APC pricing.
  • PC proficiency preferably with Microsoft Word and Excel and FACETS.
  • Ability to work well under pressure work with frequent interruptions and shifting priorities.
  • Maintain confidentiality and project a professional business image.
  • Identify root causes of claim problems and trends while participating in the development of potential solutions.
  • Strong ability to work within a team environment as well as independently.

    • Primary Functions :

  • Identify root cause of claims problems trends and participate in developing solutions. This includes performing research through available systems policies and departments ensuring timely resolution.
  • Develop and review Dashboard metrics (quality financial triple AIM) and translate into actionable items based on group specifics.
  • Ability to provide actionable financial and operational data and to ensure action plans are implemented to achieve performance goals.
  • Work in a consultative role with various departments locally creating effective information and analyses to optimize the markets strategic objectives for providers.
  • Provide timely responses to all provider inquiries within in three business days.
  • Conduct regular on-site provider visits to create strategic provider partnerships to improve health efficiencies and foster provider experience while ensuring cohesion across product lines with Modas policies. All providers should be provided with an invitation for such on-site visits. There should be a minimum of 36 visits on average per year (three per month).
  • Educate providers on their health plan contract language ensuring consistent interpretation.
  • Organize prepare and present annual Provider Workshops. Workshops are our opportunity to foster relationships provide education and represent Moda in a positive light.
  • Participate in ongoing Moda committees with the expectation of providing feedback and recommendations from the Provider Relations perspective while bringing back pertinent information.
  • Utilize necessary resources tools and navigate systems efficiently to provide accurate and timely responses to inquiries
  • Represent Moda in a positive and professional manner at all times.
  • Collaborate with other teams peers and management to identify areas of inefficiency and process improvement opportunities.
  • Other duties as assigned

    • Working Conditions & Contact with Others

  • Office environment with extensive close PC and keyboard work constant sitting and phone work. Must be able to navigate multiple screens. Work in excess of 40 hours per week including evenings and occasional weekends to meet business need.
  • Internally with Health Services Sales Contracting Network Adequacy Compliance Customer Service Marketing Underwriting Claims Claims Support and Document Services. Externally with contracted providers clinic administrators hospital executives provider billing staff and IPA administrators.

    • Together we can be more. We can be better.

    Moda Health seeks to allow equal employment opportunities for all qualified persons without regard to race religion color age sex sexual orientation national origin marital status disability veteran status or any other status protected by law. This is applicable to all terms and conditions of employment including recruiting hiring placement promotion termination layoff recall transfer leaves of absences compensation and training.

    For more information regarding accommodations please direct your questions to Kristy Nehler & Danielle Baker via email.

    Key Skills

    Hp Unix,Administration & Operation,Ado,IT Security,Management Administration

    Employment Type : Full-Time

    Experience : years

    Vacancy : 1

    Yearly Salary Salary : 2 - 4

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