Provider Resolution Director - Government Business Division (JR132801)
Location: Candidates must reside within 50 miles or 1-hour commute each way of the above Elevance Health PulsePoint location.
Elevance Health supports a hybrid workplace model (virtual and office) with PulsePoint sites used for collaboration, community, and connection, with the in-office commitment for this role being 1-2 days in an office per week.
The Provider Resolution Director is responsible for developing and maintaining positive provider relationships, dedicated to National Facility/ Ancillary provider groups with total annual spend up to $1B. May also be focused on multiple Facility contracts in one state or across a particular region of the state.
How will you make an impact:
Conduct or collaborate on regular on-site and/or virtual/digital visits, communicates administrative and programmatic changes, and facilitates education and the resolution of provider issues.
Serving as a knowledge and resource expert regarding the most complex National Facility/Ancillary provider issues impacting provider satisfaction, researches and resolves the most complex provider issues and appeals for prompt resolution.
Where the individual is focused on one state or across a particular region of the state, that individual shall take on a "Senior" role in collaborating with existing resolution staff as well as with their assigned accounts.
They will work with internal matrix partners to triage issues and submit work requests.
Functions as a high level technical resource to resolve or facilitate complex provider issues, both internally and externally.
Leads (or co-leads) Joint Operation Committees (JOC) of National Facility/ Ancillary provider groups or state-specific or regional accounts, driving the meetings in the discussion of issues and changes, specifically highlighting strategic opportunities.
Provides assistance regarding Annual Satisfaction Surveys and required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues.
Coordinates (or collaborates in) communications process on such issues as administrative and medical policy, reimbursement and provider utilization patterns.
Coordinates (or collaborates in) prompt claims resolution through direct contact with providers, claims, pricing and medical management department.
Manages inventory impacting up $500M A/R, conducts claim and trend analysis.
Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery.
Researches issues that may impact future provider negotiations or jeopardize network retention.
Shall provide mentorship, training, guidance to PRMs.
Minimum Requirements:
Bachelor's degree and a minimum of 5 years of Provider service experience including 5 years' experience healthcare or provider environment; or any combination of education and experience, which would provide an equivalent background.
Preferred Qualifications:
Experience in any combination of Provider Resolution, Provider Data, Provider Relations, Provider Network Management, Contracting - within Medicaid a plus.
Claims Experience including handling complex claims and ensuring claim payment accuracy is highly preferred.
Provider Relations/Provider experience is highly preferred.
Contracting and Credentialing experience is preferred.
Understanding of Provider Data and Operations.
Experience with high level provider escalations.
Experience translating contract language into maintenance of data.
Experience presenting to leadership / executives.
For candidates working in person or remotely in the below location, the salary* range for this specific position is $114,072 to $195,552
Location: New York
In addition to your salary, Elevance Health offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). The salary offered for this specific position is based on a number of legitimate, non-discriminatory factors set by the Company. The Company is fully committed to ensuring equal pay opportunities for equal work regardless of gender, race, or any other category protected by federal, state, and local pay equity laws.
* The salary range is the range Elevance Health in good faith believes is the range of possible compensation for this role at the time of this posting. This range may be modified in the future and actual compensation may vary from posting based on geographic location, work experience, education and/or skill level. Even within the range, the actual compensation will vary depending on the above factors as well as market/business considerations. No amount is considered to be wages or compensation until such amount is earned, vested, and determinable under the terms and conditions of the applicable policies and plans. The amount and availability of any bonus, commission, benefits, or any other form of compensation and benefits that are allocable to a particular employee remains in the Company's sole discretion unless and until paid and may be modified at the Company's sole discretion, consistent with the law.
