JOB RESPONSIBILITIES

• Bachelor’s degree and one year of managed care experience in products or contracts OR 3 years’ direct experience in a managed care environment with one year experience in claims, pricing, products, regulatory compliance or contracts.   
• One year direct experience in a position that demonstrates relationship abilities and sound decision-making.
• Prepare credentialing files for submission to credentialing committees and payer organizations; and maintain accurate provider records in credentialing and provider management systems.
• Ability to meet deadlines and work well under pressure and take initiative to work independently. 
• Excellent verbal and written communication skills; strong organizational and planning skills. 
• PC proficiency to include Microsoft Office with exceptional Excel knowledge; proficiency with PowerPoint, Sales Force. 
• Ability and willingness to travel locally for trainings.   

PREFERRED JOB RESPONSIBILITIES

• One year of direct experience in provider relations. 
• Knowledge and experience in provider reimbursement methods.  
• Advanced proficiency with Salesforce. 
• Experience with Premier Provider Web. 

~ KEY FUNCTIONS ~

• Interact with provider organizations to provide information on HCSC billing, claims procedures and compliance.   

• Identify and coordinate resolution of reoccurring issues and policies between providers and internal departments (e.g.: PASS, contracting, NOSD, etc.) 

• May participate in provider meetings to identify, develop, and monitor potential areas of improvement that will strengthen the ongoing relationship with the provider. 

• Build a working knowledge of HCSC claims processing and reimbursement methodologies.  

• Assist with provider orientation, training and policy education to provider office staff, billing staff and referral/precertification areas.  Ensure providers are informed when changes occur in network state plan or HCSC policies and procedures and provide appropriate education/in-service.   

• Respond to provider inquiries in a timely manner and help in claims resolution and payment problems, engaging with internal partners including, but not limited to PASS, NOSD, contracting.   

• Establish relationships with providers through correspondence and telephone calls. 

• Participate in workgroups to enhance provider experience, including develop improvements to common internal or provider pain points.  

• Represent provider perspective and timelines when working with Internal departments on the resolutions of provider issues (e.g.: Claims, roster updates, pricing, etc.) 

• Communicate and interact effectively and professionally with co-workers, management, customers, etc.       

• Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies. 

• Maintain complete confidentiality of company business. 

• Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested. 

• Responsible for maintaining an up-to-date tracker of provider concerns and pain points.  Participate in discussions around resolutions. 

• Assist providers and/or internal teams to assure HCSC meets and/or exceeds standards and guidelines for regulatory compliance including provider directory reviews, annual training tracking and other compliance related items ex. Secret Shop, HCAPA, dormancy review).  

• Assist with data inquires and resolutions as required (e.g.: CAQH, PPW, NPI Crosswalk, Claims lists, roster requests, etc.  

• Maintain accurate and timely documentation within Salesforce, ensuring all provider interactions, outreach activities, issue resolution, and key relationship management details are consistently recorded and updated to support business operations, reporting, and performance tracking. 

• Provide project support as needed, including tracking milestones, managing timelines, coordinating cross-functional activities, and contributing to project documentation and status updates. 

• Other duties as assigned by leadership. 

NOTE:  relocation is NOT offered; sponsorship is NOT available either now or in the future.   This role is hybrid/flex and requires in-office visibility three days per week, working from home the other two days.