Peak Health

Provider-led health insurer with Medicare Advantage

Network Service Consultant

InsuranceConfirmed live in the last 24 hours

Full-timeRemote in USANo salary listed

About the Job

Requirements

A bachelor's degree in business or a healthcare-related field is required.
Understanding of contracts, value-based reimbursement and/or performance-based provider reimbursement programs, and Commercial, Medicare Advantage, Medicaid, and PEIA products is preferred.
Understanding of regulatory reporting for provider networks, including the West Virginia Department of Insurance, Department of Medicaid/Health Services, and the Centers for Medicare & Medicaid Services, is preferred.
Understanding of provider quality measurement systems and programs such as Medicare STARS, Healthcare Effectiveness Data and Information Set, and Patient-Centered Medical Home quality programs is preferred.
Knowledge of federal and state laws, including Centers for Medicare & Medicaid Services requirements, is required.
Proficiency with Microsoft Office is required.
Experience with Commercial, Medicare, and Medicaid products is required.
Understanding of provider credentialing and data management processes is required.
Working knowledge of claims and/or coding is required.
Established provider relationships in West Virginia are required.
The role requires attention to detail, strategic thinking, written and oral communication, and the ability to build and retain relationships.

Responsibilities

Develop and maintain collaborative relationships with physicians, hospitals, ancillary providers, vendors, and other stakeholders.
Shape the provider network landscape by offering objective data and education across stakeholders, markets, and product lines.
Educate providers on policies and procedures related to credentialing, contracting, authorizations, referrals, claims and encounters, grievances and appeals, health education, provider education, population health management, care management, pharmacy management, electronic health records, medical record submissions, health information exchange, data exchange, electronic data interfaces, and regulatory updates.
Conduct periodic provider outreach through email, telephone, in-person meetings, and scheduled webinars.
Assess provider efficiency in dealings with the health plan.
Conduct initial provider orientations and ongoing educational outreach.
Conduct group training sessions.
Assist with provider contract questions by researching problems and resolving escalated issues.
Represent the health plan at healthcare association functions such as HFMA, MGMA, and AMA events.
Participate in regulatory reporting for provider networks, including reporting to the West Virginia Department of Insurance, Department of Medicaid/Health Services, and Centers for Medicare & Medicaid Services.
Monitor competitors and market regulations.
Support strategic positioning in geographic areas to develop and maintain provider networks.
Assist the Credentialing Department with difficult-to-obtain documents.
Maintain communication channels with Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing, and Member and Provider Services to resolve issues and advance team and business priorities.
Travel to offsite meetings as required.

Desired Qualifications

A master's degree in Healthcare Administration or Business Administration is preferred.
Certified Medical Coder certification through the American Academy of Professional Coders is preferred.

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.

This role will be responsible for the development and maintenance of collaborative relationships with providers (physician, hospital, ancillary, vendors etc.) based on mutual respect, high-quality outcomes, and patient and provider satisfaction. The role works to continually shape the network landscape, by offering objective data and education to all stakeholders in the market and all product lines. The incumbent will report to the Manager Network Services and will be an integral and collaborative member of the Provider Relations team.
The incumbent will be detail oriented and an excellent communicator who is ready to take on a new, challenging career in the market!

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree in business, or healthcare related field

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Master’s Degree in Healthcare Administration or Business Administration

2. Certified Medical Coder (CMC)through the American Academy of Professional Coders (AAPC)

EXPERIENCE:

1. Basic understanding of Contracts, Value Based Reimbursement (VBR) and/or performance-based provider reimbursement programs, and Commercial (fully insured and self-funded), Medicare Advantage, Medicaid, PEIA products.

2. Understanding of Regulatory Reporting for provider networks, e.g., WV Department of Insurance, Department of Medicaid/Health Services and CMS.

3. Understanding of provider quality measurements and systems such as Medicare STARS, HEDIS, and PCMH quality programs.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Upholds the health plan mission of making make healthcare more accessible, understandable, and collaborative while interacting with providers and colleagues.

2. Educates providers regarding policies and procedures related to credentialing, contracting, authorizations, referrals, claims and/or encounters, grievances and appeals, health education, provider education, population health management, care management, pharmacy management, Electronic Health Records and medical record submissions, Health Information Exchange, data exchange and electronic Data Interface and regulatory updates.

3. Builds and maintains strong provider relationships.

4. Conducts routine periodic outreach to providers based upon business plan and operational goals to include e-mail, telephone, in-person, and scheduled webinar meetings.

5. Ongoing assessment of provider efficiencies when dealing with health plan.

6. Conducts initial provider orientations as well as ongoing educational outreach.

7. Conducts group training sessions.

8. Assists with simple provider contract questions including researching problems and resolving escalated issues.

9. Represents health plan at healthcare association functions i.e. HFMA, MGMA, AMA

10. Participates in regulatory reporting for provider networks, e.g., WV Department of Insurance, Department of Medicaid/ Health Services and CMS.

11. Keep abreast of competitors and regulation in market.

12. Supports strategic positioning in geographic areas to develop and maintain provider networks.

13. Assist Credentialing Department with any difficult to obtain documents.

14. Initiates and maintains effective channels of communication with matrix partners including but not limited to, Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing and Member and Provider Service, to resolve issues and facilitate team and business priorities/opportunities.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1 Standard office environment

2. Some travel may be required to offsite meetings

SKILLS AND ABILITIES:

1. Strategic thinking and attention to detail

2. Knowledge of federal and state laws, such as CMS, BMS, etc.

3. Excellent written and oral communication

4. Demonstrated ability to build and retain relationships

5. Proficiency with Microsoft Office

6. Experience with Commercial (self-funded and fully funded), Medicare and Medicaid products.

7. Understanding of the provider credentialing and data management process.

8. Working knowledge of claims, and/or coding.

9. Established provider relationships in West Virginia

Additional Job Description:

Other duties asassigned

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2901 PHH Provider Management

About the Company

Peak Health

Provider-led health insurer with Medicare Advantage

Peak Health is a provider-led health insurer operating primarily in West Virginia, linking hospitals and clinics with the insurer to align incentives and improve member care. It offers health plans including Medicare Advantage PPOs and employer-group options, such as the Peak Advantage plan designed with local doctors and health systems to ease access, billing, and communication. It differentiates itself by being locally based and provider-owned, collaborating with WVU Health System, Marshall Health Network, and Valley Health, and expanding Medicare Advantage to more counties in West Virginia and Pennsylvania. Its goal is to make healthcare more accessible and affordable for communities by reducing friction in care and billing and by expanding services to employers and self-funded groups.

Company size: 51-200
Company stage: Not listed
Total funding: Not listed
Headquarters: Morgantown, WV
Founded: Not listed

Recently Posted Jobs

Explore more opportunities at Peak Health

See more jobs