Network Relations Consultant

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The Network Relations Consultant is responsible for assigned network PCP performance including PAHAF completion, AWV and Star rating of 4 or above.

• Develop and maintain positive provider relationships with the provider community through regular on-site visits, communication of administrative and programmatic changes, and facilitation of education and resolution of provider issues.
• Serve as a knowledge and resource expert regarding provider issues impacting provider satisfaction, researching and resolving complex provider issues and appeals for prompt resolution.
• May be responsible for coordinating non-negotiated contracts for new and existing providers as needed.
• Research, analyze and recommend resolution for contract disputes, non-routine claim issues, billing questions and other practices.
• May participate in Joint Operation Committees (JOC) of larger provider groups.
• Coordinate communication processes on issues such as administrative and medical policy, reimbursement and provider utilization patterns.
• Conduct seminars to support understanding of managed care policies and procedures.
• Identify network access and deficiencies and develop recruitment and contracting strategies.
• Coordinate and conduct provider training including developing and distributing provider relations materials.
• Provide quality, accessible and comprehensive service to the company's provider community.
• Assist with education, contract questions and non-routine claim issues.
• Coordinate communications process on issues such as administrative and medical policy, reimbursement and provider utilization patterns.
• Coordinate prompt claims resolution through direct contact with providers, claims, pricing and medical management departments.
• Identify and report on provider utilization patterns that directly impact the quality of service delivery.
• Track and conduct provider refresher training.
• Research issues that may impact future provider negotiations or jeopardize network retention.

• Requires a Bachelor's degree.
• Minimum 3 years of customer service experience, including 2 years as a Network Management Representative, or equivalent education/experience.
• Travel to worksite and other locations as necessary.

• Consistent PCP visits focused on:
• PAHAF completion, STAR gaps closed
• HCC Re-capture rate
• PCP referrals

• Model of Care
• Portal usage/training for referrals and authorizations
• New PCP onboarding

• Claims
• Referrals and authorizations
• G&A
• Compensation: national market average; position bonus-eligible based on individual and company performance.

$80,819.00 to $

• Mid-Senior level

• Full-time

• Information Technology
• Hospitals and Health Care