Location: Alternate locations other than the posted locations may be considered. This position will work in a hybrid model (remote and office). The ideal candidate will live within 50 miles of one of our Elevance Health PulsePoint locations.
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:
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 preferred.
