GENERAL SUMARY AND PURPOSE:

This position is responsible for managing the daily network operations including but not limited to: customer and provider relations, credentialing and provider file maintenance.  Provides training, quality reviews, issue resolution and input during performance appraisals within the assigned work team.  In conjunction with the Saint Alphonsus Health Alliance (SAHA) and Saint Alphonsus Health Systems (SAHS), acts as a contact and works in cooperation with internal departments including shared services, data analytics, finance, credentialing, and contracting.  Leads the process for completion of Alliance Participation Agreements.  Responsible for the resolution of provider claims issues for SAHS and SAHA and ensuring network providers and internal colleagues understand payer and physician participation requirements.  Assists the Regional Director and President as needed.

Externally, responsible for building and maintaining relationships with providers both owned and independent, by providing a high level of customer service.  Leads the work necessary for resolution of questions regarding claims, fee schedules, network contracting, provider credentials verification, payer enrollment, and network procedures. 

SKILLS, KNOWLEDGE, EDUCATION AND EXPERIENCE:

Bachelor's degree preferred. Eight years of experience in healthcare may be considered in lieu of degree.

Minimum of five years' experience working with managed care contracts, healthcare billing and customer service required.

ESSENTIAL FUNCTIONS:

Knows, understands, incorporates, and demonstrates the Organizational Mission, Core Values, and Vision in behaviors, practices, policies and decisions. Manages the operational work for SAHA provider credentialing and SAHA provider file maintenance under the direction of the SAHA President. Provides guidance and support to credentialling and operations colleagues. Creates, updates and disseminates policy/procedures.  Serves as technical advisor and resource to the colleagues. Provides operational guidance and support to Regional Director. Creates, updates and disseminates policy/procedures.  Serves as technical advisor and resource to Payer Strategies colleagues, the Regional Director and Patient Business Services (PBS).

Develops effective decision-making, communications, and interpersonal relations to ensure a positive image of SAHA and SAHS, and to ensure customer satisfaction, supporting and portraying strong customer service philosophies in all encounters. Represents Payer Strategies at claims resolution meetings with the PBS and insurance companies. Provides timely and professional follow-up to providers' complaints and assists internal colleagues and providers with reported issues; and ensures problem resolution and corrective action for long-term solution, coordinating such effort across intra and inter-departmental channels.

Provides function-specific training, including staff orientation and continuing education. Analyzes and displays data in meaningful formats; develops and communicates policies/procedures and other business documentation; conducts special studies and prepares management reports, including key performance Indicators as they relate to the division (waiting/service times, colleague productivity, accuracy, customer feedback, incident reporting, etc.).

Reviews credentialing contract proposals to ensure compliance with standards and guidelines. Responsible for issuing new network Participation Agreements for all network provider types. Assists Contract Specialist in verifying contract terms, amendments, and policy terms. Adheres to all established contracting guidelines. Manages a team of credentials coordinators and file maintenance colleagues.  When applicable assures these colleagues maintain appropriate certification and strictly adheres to industry criteria (NCQA) required by insurance companies for delegated credentialing services. Supports insurance company audits of credentialing services. 

Responsible for ensuring that department promptly responds to and corrects any deficiencies identified during these audits.  Assures provider calls, emails, faxes are handled accurately and promptly. Resolves administrative problems affecting, network credentialing, network providers and PBS colleagues. Responsible for accurately creating and maintaining SAHA Participating Provider contract files and provider file maintenance databases. Assists with mailings, tracking spreadsheets and other related duties, including audits, and tracking and trending analysis as may be assigned.

Engages providers in building positive, long-term consultative relationships while promoting value-added initiatives/services. Resolves claims issues while maintaining positive relationships. Successfully completes special projects related to job as assigned by management.   Travels across territory to meet with providers.  Coordinates directly with internal departments and colleagues to identify, report, track, and communicate resolution. Maintains confidentiality and protects sensitive data at all times. 

Colleagues of Saint Alphonsus Health System enjoy competitive compensation with a full benefits package and opportunity for growth throughout SAHS and Trinity Health.

Visit www.saintalphonsus.org/careers to learn more about the benefits, culture and career development opportunities available to you at Saint Alphonsus Health System.

Saint Alphonsus and Trinity Health are committed to promoting diversity in its workforce and to providing an inclusive work environment where everyone is treated with fairness, dignity and respect. We are committed to recruit and retain a diverse staff reflective of the communities we serve. Saint Alphonsus and Trinity Health are equal opportunity employers and prohibit discrimination against any individual with regard to race, color, religion, gender, marital status, national origin, age, disability, sexual orientation, or any other characteristic protected by law.

Our Commitment to Diversity and Inclusion
 

Trinity Health is one of the largest not-for-profit, Catholic healthcare systems in the nation. Built on the foundation of our Mission and Core Values, we integrate diversity, equity, and inclusion in all that we do. Our colleagues have different lived experiences, customs, abilities, and talents. Together, we become our best selves. A diverse and inclusive workforce provides the most accessible and equitable care for those we serve. Trinity Health is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, status as a protected veteran, or any other status protected by law.