What are the responsibilities and job description for the Network Management Representative position at Hawaii Medical Service Association?
Network Management Representative
#24-6359
Honolulu, Hawaii, United States
Employment Type
Full-time
Exempt or Non-Exempt
Exempt
Job Summary
Pay Range: $53,00 - $99,000
Note: Individuals typically begin between the minimum to middle of the pay range
PRIMARY PURPOSE: Manages both individual and group provider relationships with HMSA to include provider recruitment, standard contracting, onboarding, claims training and resolution of providers' issues including those related to claims payment, quality and performance initiatives, improved access and controlling unnecessary costs. Ensures that contract and regulatory network adequacy requirements are met by continuously developing new provider relationships while strengthening existing relationships. Supports the implementation of business changes to simplify operations and improve all provider business experiences with HMSA.
Requires regular off-site visits to resolve servicing issues, gather provider market intelligence, contract related concerns and provide education ( 50% of time spent offsite) to ensure and strengthen relations with providers. Position is eligible for priority parking. Requires safely operating an insured automobile for travel to off-site locations to conduct and accomplish business related activities. Must have a valid driver's license, access to an automobile with current license, registration and no fault insurance.
Minimum Qualifications
- Bachelor's degree and two years related experience; or an equivalent combination of education and experience.
- Excellent verbal and written communication skills.
- Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, PowerPoint, and Outlook.
- Valid U.S. drivers license, access to an automobile with current registration and insurance.
Duties and Responsibilities
a. Responsible for initiating and providing face-to-face support to new providers interested in joining HMSA's network. This includes, but is not limited to, contracting and on-boarding to ensure that there are no unnecessary delays in the process. It involves conducting new provider orientation & on-going training related to claims filing, E-Library, HHIN, reimbursements.
- ing problem-solving techniques as it relates to dispute resolution to include, but not limited to, HMSA's provider contract definition, application of payment or medical policies, provider operations that involve posting claims payments, and complaints made through the Insurance Commissioner's office within timeframes required by the Insurance Division or by HMSA as stated in the provider contract.
- Through positive direct in-person interactions with providers, build a collaborative and trusting relationship that leads to understanding, alignment and buy-in to HMSA programs and processes. Conducts proactive and requested field visits to provider's offices to gain market intelligence, support, drive behavior change, and provide guidance on HMSA business initiatives including, but not limited to, changes in claims processing, reimbursement, policies, promotion of self-service tools, and support of various complex HMSA programs. Participates and attends Community or Provider sponsored events representing HMSA in support of a viable, accessible provider network.
- Develops the content and coordinates with educators and SME's as appropriate to maintain and implement operational content used to train both Provider Servicing staff and Providers' business offices. Coordinate and conduct education activities involving providers, Provider Services and other HMSA departments with the objective to modify inefficient claim filing behaviors and to implement operational business changes. Supports development and implementation of policy changes on behalf of Provider Services and communicates the provider perspective when representing the department on cross-functional teams, corporate initiatives, and tactical objectives.
- Works with Network Management analyst to identify and fill network gaps and propose strategies to fill gaps through the following actions:
- Recruitment of new providers by researching and developing relationships with non-contracted providers to build a cost-effective, high quality provider network
- Expansion of current providers via additional locations, panel growth, or new technology.
- Coordinates case resolution with internal business areas to respond (in writing, telephonic, or face-to-face) timely and accurately to provider inquiries regarding claims, benefits and complex issues that include medical or payment policy questions and provider appeals. Proactively resolve problems to ensure compliance with contract terms and resolve problems due to system programming to build trust and strong business relations with all providers.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.
