Excellus Health Plan Inc.
Behavior Health Children Provider Relations Representative I/II/III - 014407 (Biotech)
This position serves as the primary contact between the provider and the organization; supporting behavioral health providers including ancillary, professional, facilities, health homes and HCBS providers; and any providers who support Medicaid Managed Care and Health and Recovery Program; known as HARP. The position is responsible for servicing assigned providers within a defined geographic market. Key responsibilities include provider education to in-network behavioral health providers; this position will work closely with medical provider relations representatives to educate primary care physicians on BH integration approach. The position assures timely inter-provider referrals and associated appointment access; assists in resolving provider issues including resolving grievances, disputes between providers and the investigation of member grievances regarding providers; coordinates provider site visits, reviews provider profiles, and implementation and monitoring of corrective action plans and quality of care. Additionally; this position works closely with other internal departments including sales, medical, operations and network management. As a key representative of the corporation, this position is expected to maintain strong communication and build positive working relationships with local physicians, hospitals and ancillary providers.
Essential Responsibilities/Accountabilities
Knowledge of the provider system serving children with Behavioral Health needs, in foster care and/or medically fragile and evidence based practices.
Familiar with recovery-oriented services, an understanding in children's health and BH services (HCBS services for children, EBPs, TAY, Trauma Informed) and social service programs (children in Foster Care with Developmental Disabilities or Medically Fragile Children).
Facilitates provider education and training through documented face-to-face visits educational forums in order to increase provider knowledge and satisfaction with the terms of their contract. Provides education to ensure that providers understand compliance with NYS behavioral health standards as well as requirements from all regulatory agencies.
Provides orientation, training and educational materials for all newly enrolled providers and their staff as well as annual training to the overall provider community.
Educates providers on behavioral health care management programs, access to care standards, policies, and quality initiatives including but not limited to UM programs, case and disease management, HEDIS, health and wellness programs and pay for performance (P4P) or other quality initiatives in order to improve compliance and participation.
Educates, coordinates and collaborates with network providers to redesign practice operations in alignment with Health Home (HH) designation standards.
Coordinates with Medical services to analyze and present data to providers in order to increase participation and/or compliance within established programs and improve member health status.
Builds physician, provider and facility satisfaction by conducting service visits both in response to provider requests and on behalf of the organization. Plans, initiates, develop, coordinate and documents visits in conformance with availability of providers, department standards and geographic assignment.
Maintains awareness of competitive activity through relationships developed with providers and their office staff. On an ongoing basis, as part of monthly reporting, documents information regarding market position including all competitive intelligence that would enable the organization to position ourselves favorably and successfully respond to the provider.
Provides expertise, assistance and training with guidelines relative to provider billing, coding, data interface, documentation requirements; encouraging participation with programs and procedures designed to create operational efficiencies. Ensures that providers are familiar with standard billing practice and that changes in billing procedures are communicated on a timely basis to all providers. Provides accurate feedback to internal departments to improve accuracy of system interfaces.
Serves as an internal expert and develops working relationships with internal departments in order to facilitate workflows and coordinate appropriate resources for problem resolution for providers. Identifies and communicates trends that impact provider satisfaction.
Provides support for the organization to participate in regional and statewide activities to maintain strong behavioral health provider networks that support access to care.
Participates in the development of effective provider tools and communications. Creates and maintains information such as provider manuals, newsletters, mailings, provider directories and other education and publication materials distributed by the organization to providers.
Ensures that processes are being appropriately documented to support the ongoing operations.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
Companies' mission and values and adhering to the Corporate Code of Conduct.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies' mission and values, adhering to the Corporate Code of Conduct, and Leading to the Lifetime Way values and beliefs.
Maintains knowledge of all relevant legislative and regulatory mandates and ensures that all activities are in compliance with these requirements.
Level II – performs additional functions such as:
Assists with training and mentoring of junior Provider Relations Representatives as needed to ensure departmental success. Provides project management support as required.
Assists in developing and coordinating provider educational activities.
Level III – performs similar functions as levels I & II, as well as:
Represents the Provider Relations department on Health Plan projects/initiatives.
Develops, coordinates, and leads provider educational activities.
Represents the Provider Relations department at Regional and Health Plan meetings as assigned by management.
Represents the organization on regional or state-wide councils to support ongoing program development to improve delivery of care models.
Acts as the subject matter expert and point of contact for the department.
Provides leadership and guidance to junior Provider Relations Representatives.
Minimum Qualifications
Bachelor's degree in, Behavioral Health, Business Administration, Health Care Administration or relevant field with relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
In lieu of a Bachelor's degree individual must have experience that includes experience working in a BH managed care setting or BH clinical setting and expertise in the management of provider BH services for children, Transition age youth; high risk groups such as individuals with Serious Mental Illness (SMI) co-occurring major mental disorders and Substance Use Disorders (SUDs) and those involved in multiple services systems (education, justice, medical, welfare, and child welfare);Individuals with Intellectual or Developmental Disabilities (I/DD) in need of BH services; individuals with a Mental Health (MH) condition or a SUD and co-occurring chronic physical health conditions; and Individuals with a SUD in need of medication-assisted treatment, including methadone and buprenorphine for opioid dependence. :
Experience shall include knowledge of recovery-oriented practices and development of EBPs recognized by the Substance Abuse and Mental Health Services Administration (SAMHSA) and other national registries. Evidence based practices include but are not limited to wellness self-management, supported employment, family psychoeducation, Assertive Community Treatment (ACT), and Integrated dual disorder treatment (IDDT).
Experience handling escalated executive inquiries, training and/or presentations for staff or external customers and management of workload outside of determined Customer Service databases or workflows. Experience with complex and higher profile projects that involve both written and verbal responses to physician or hospital inquiries.
Minimum of two years relevant experience (level I); minimum of four years relevant experience (level II), minimum of six years relevant experience (level III).
Must possess strong, persuasive and effective communication skills including previous experience with delivering communication to physicians and hospitals.
Experience in preparing and delivering oral presentations to individuals and small and large group audiences.
Understanding of medical care delivery and local market dynamics
Knowledge of provider contracts and operational policies and procedures
Understanding of products and services offered to Members
Understanding of the Facets claim processing systems, claim workflows, provider files and other systems to facilitate provider operational improvements.
Knowledge of care management programs and their impact to Providers and Members
Knowledge of state regulations and other regulatory requirements,
Strong interpersonal skills with ability to interface effectively both externally and internally with a wide range of people including physicians, office staff and other health plan staff.
Excellent problem solving skills with effective follow through
Strong verbal and written communication skills; organizational and project management skills.
Must have ability to travel.
Physical Requirements
Travel is required to complete required face to face visits and educational forums.
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The Lifetime Healthcare Companies aims to attract the best talent from diverse socioeconomic, cultural and experiential backgrounds, to diversify our workforce and best reflect the communities we serve.
Our mission is to foster an environment where diversity and inclusion are explicitly recognized as fundamental parts of our organizational culture. We believe that diversity of thought and background drives innovation which enables us to provide leading-edge healthcare insurance and services. With that mission in mind, we recruit the best candidates from all communities, to diversify and strengthen our workforce.
OUR COMPANY CULTURE:
Employees are united by our Lifetime Way Values & Behaviors that include compassion, pride, excellence, innovation and having fun! We aim to be an employer of choice by valuing workforce diversity, innovative thinking, employee development, and by offering competitive compensation and benefits.
In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.
Equal Opportunity Employer
Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities
The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor's legal duty to furnish information. 41 CFR 60-1.35(c)
Non Manager