Provider Network Representative

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit Amida Care for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced leader to join our team as the Provider Network Representative. Compensation will be commensurate with experience.

Position Summary:

This position develops, contracts, maintains, and enhances relationships with facilities, physicians and ancillary providers within designated geographic area(s) to drive business results. This position is responsible for the appropriate representation of providers relating to contractual arrangements, compliance, regulatory, credentialing, claims, provider files and administrative policy and procedures. This position may be assigned to service sponsors and/or other large provider entities, possibly in multiple boroughs.

Responsibilities:

• Successfully execute all processes to support the Provider Directory and other pertinent reports. This includes, but is not limited to, modifications of records to assure appropriate support of business processes and all other activities in a timely manner and ensure provider data accuracy in systems.
• Conducts limited negotiations and drafts contract amendments.
• Conduct regular service visits to ensure provider service needs are met, resolve issues, educate providers and provider staff on policies and the web-portal usage, collect credentialing information, and review Healthcare Effectiveness Data and Information Set (HEDIS) information, etc.
• Work closely with key Departments to ensure successful implementation of Provider Agreements from initiation to approval, including provider credentialing applications, environmental site reviews, system configuration, and orientation.
• Serve as plan liaison for physicians/physician groups in a specified geographical area. Will be main point of contact for all plan-related issues including contracting, billing and reimbursement. Responsibility for the resolution of all issues, including those identified by the provider, and those identified internally that have an impact on the physician.
• May participate in intradepartmental projects or smaller projects impacting multiple departments.
• Responsible for the oversight of the delegated provider roster process and ensures timely and accurate updates.
• Operates with general supervision, elevating unusual situations to management as required.
• Responsible for appliable compliance and regulatory and related tasks.
• Educate new providers and their staff on current Amida Care Policies and Procedures.
• Recruits' key providers into the Amida Care Network based on a Network Gap Analysis.
• Identify potential claims trends, identify systems trends, and correct root causes for organization's provider systems data issues.
• Monitor contracts to ensure contract administration objectives are achieved and oversee provider data quality assurance.
• Chair regular contract relations meetings with key groups.
• Perform other duties as assigned.

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

EDUCATION REQUIRED

• Bachelor's degree in health care administration, business or an equivalent combination of education and work experience in managed care or health care.

EXPERIENCES AND/OR SKILLS REQUIRED

• Minimum of five (5) years' experience in health care; including a minimum of three (3) years in provider/ payor contracting.
• Proficiency in Microsoft Office software (Word, Access, Excel).
• Ability to travel efficiently and continuously to and within assigned geographic area.
• Strong organizational and project management skills.
• Demonstrate appropriate behaviors in accordance with the organization's vision, mission, and values