The Provider Network (PN) Liaison, in conjunction with the whole MSO Provider Network team, is responsible for activities and actions related to promoting the services and expertise of NEMS' network and MSO services to the medical community, as well as providing the community with ongoing education regarding the NEMS managed care services.
The PN Liaison is responsible for a wide range of communication activities to support, develop and maintain service relationships with all community participants (physicians, hospitals and health systems, providers and administrators) of the NEMS MSO network, including network adequacy according to DHCS & CMS standard, with primary focus on conducting in-person orientation/education/communication events to external provider organizations, establishing and maintaining positive relationships with providers and referral sources, responding to provider and client requests and concerns, and negotiating service contracts with community providers and organizations.
The position exercises discretion and independent judgment to respond to complex inquire about MSO provider network policies, contracts, reimbursement rates, managed care policies changes, referrals, credentialing, provider appeals and member grievances, etc. provides managed care training, educations, and guidance and to manage provider communication efforts. The PN Liaison, works with the PN Liaison Lead, as the face of the pro contact of NEMS to the community for the overall medical management communications and plans.
The PN Liaison is required to have the ability to communicate efficiently, with a variety of professionals, to build effective working relationship, including physicians and other healthcare providers, business administrators and contracting managers, billing, and revenue cycle agencies; works on projects and matters with levels of complexity in a support role.
The position requires critical thinking skills, able to independently trouble-shoot and resolve complex provider network related issues. This position also requires relevant knowledge to HMO, Medicare and/or Medi-Cal Risk Plan, benefits, managed care programs and sufficient level of understanding to CMS/DHCS health policy.
This is primarily a field-based position that requires 60% local travel in Northern California.
Previous field-based experience is a plus. A self-starter with excellent time management, critical thinking, and great interpersonal skills. Must have a California driver's license as travel is required. Must be able to multi-task and be familiar with MS Word, PowerPoint, Excel, various video conference systems.
ESSENTIAL JOB FUNCTIONS:
Develop new and maintain existing business relationships with community organizations, physicians, and healthcare administrators via in-person outreach activities according to pre-determined targeted market or geographic area.
Plan and conduct independent in-service meetings that will highlight the features and benefits of NEMS network and to promote NEMS MSO services while responding to complex provider inquires and addressing concerns.
Represent NEMS MSO at networking and community events throughout an assigned territory.
Exercise discretion and independent judgment to address complex authorizations, claims, provider appeals, benefit coverage issues raised by physician practices during outreach event, and to coordinate follow up activities via virtual or in-person meetings for resolution.
Responsible to conduct orientation, training, and education sessions to contracted provider entities and business associates, to provide general guidelines of the Medicare and Medi-Cal manage care program requirements via virtual and in-person meeting.
Assist in interpreting MMCD policy and DHCS APL (All Plan Letter) and make practical efforts to communicate policy changes to community providers and organizations for implementation within required timeframe.
Assists with workflow training to new team members to ensure complete understanding of and adoption to the NEMS MSO network and programs.
Participate in the design and development of marketing materials including brochures, flyers, newsletters, and other managed care related information.
Complete provider outreach/visits log submit them on a timely basis to Provider Network Operations Manager
Collaborate with internal and external parties for implementation of audit findings.
Performs other job duties as required by manager/supervisor.
QUALIFICATIONS:
BA/BS degree; Associate Degree may be considered with relevant, equivalent work experience.
4 years work experience in healthcare setting in the areas of provider network, claims, or utilization management is preferred.
Prior experience in a managed healthcare setting, provider organization with knowledge of CMS and/or DHCS health policy is preferred.
Knowledge of Medicare and/or Medi-Cal managed care program and/or other state-sponsored program is a plus.
Superior ability to communicate (spoken and written) effectively with a variety of professionals, including physicians and other healthcare providers.
Must be PC literate - Strong Excel, Word, Power point, and Outlook skills;
Knowledge of community resources and cultural is a plus.
Detail-oriented and organized with the ability to interpret DHCS policy letters and make decisions.
Good organization and problem-solving skills.
Ability to self-manage and work with multiple departments within the organization and external clients.
LANGUAGE:
Must be able to fluently speak, read and write English.
Fluent in Chinese (Cantonese and/or Mandarin) preferred
Fluency in other languages are an asset.
STATUS:
This is an FLSA exempt position.
This is not an OSHA high-risk position.
This is a full time position.
NEMS is proud to be an Equal Opportunity Employer welcoming diversity in our workforce. Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.
NEMS BENEFITS: Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children; and company contribution to 401(k).