Ancillary Services Network Account Manager

The individual must possess experience working in a managed care setting with specific background in network development, provider recruitment, provider outreach, claim resolution, provider education and contract negotiations. Works with multiple provider types, e.g. physician, ancillary, medical groups, behavioral health or hospitals to supports a full range of contract arrangements and pricing mechanisms.

• Monitor and audit contracted ancillary providers to ensure that accurate demographic, payment and fee schedules are loaded into the HF Provider System correctly.
• Manage a network of Ancillary Providers for all lines of Healthfirst's business (such as Medicaid, CHP, Medicare, and Commercial).
• Resolve configuration issues by identifying root causes in order to prevent claims denials and to ensure claims are paid correctly.
• Facilitate meetings cross-departmentally to achieve positive outcomes in management of ancillary provider network.
• Create contracts in HF contract software and review credentialing documents submitted by Provider/facility via Universal Credentialing Data Source, The Council for Affordable Quality Healthcare (CAQH) or PDF application to ensure that all the required credentials are included and that valid documents for behavioral Providers and facilities are provided.
• Negotiate and execute Single Patient Agreements for Out Of Network (OON) Providers in order to determine the Provider's payment arrangement.
• Educate newly credentialed Providers on Healthfirst's policies and procedures such as billing and authorization requirements, utilization of Healthfirst's Provider portal, claims submission, etc., via various methods (telephonic, face-to-face, webinar, etc.).
• Analyze provider network based on monthly report to ensure that Plan is meeting Health Plan Network (HPN) State requirements.
• Identify root cause of claims issues and facilitate resolution by working closely with Reimbursement and Claims departments.
• Assist Appeals and Grievances (A&G) department by acting as liaison between Providers and A&G department to achieve favorable outcomes of member related issues, complaints, balance billing and other issues.
• Ensure that all Providers' inquiries received via email and phone call are addressed efficiently and effectively within required time-frame.
• Assist management with research and facilitation of projects related to contract updates, new product implementation and new reimbursement methodologies.