Provider Relations Represenative

Hudson Health Plan, a not-for-profit managed care organization based in Tarrytown, NY, is recognized as a leader in quality improvement, customer satisfaction, and health reform advocacy. Founded in 1986 by a coalition of community-based health centers, the organization services low-income people through Medicaid Managed Care, Child Health Plus, and Family Health Plus insurance programs, and has more then 77,000 members in New York's Hudson Valley. The company is driven by its mission: "to promote and provide access to excellent health services for all people." Drawing upon its commitment to initiatives that support equitable access to quality health care, it fosters innovative technologies that enable clinical quality initiatives and streamline the eligibility determination and enrollment process into state-funded health coverage.

 

We are currently seeking a Provider Relations Representatives (field positions) for Westchester and Dutchess/Ulster Counties.  Please see below for details.


POSITION SUMMARY:  Responsible for coordinating provider recruitment, application, credentialing, and recredentialing processes.  Functions as a liaison to Hudson Health Plan providers by arranging for orientations, resolving problems, and explaining plan policies and procedures.  Assists in medical record and medical claim review as indicated.  Assists in quality assurance functions as indicated.

 

SPECIFIC DUTIES:

 

1.  Participates in all aspects of provider recruitment including:

Network analysis to ensure that the Hudson Health Plan network meets all of the New York State and other requirements for primary care capacity and specialty availability. Identification of providers to include in the network.Solicitation of providers to include in the network.Contract negotiation, including contract language and rates.Coordination of the application and credentialing process.




 

2.  Provides network support and maintenance services based on a scheduled route within the assigned territory:

 Ensures that a Hudson Health Plan presence exists in all primary care offices.Acts as liaison between providers and Hudson Health Plan when issues arise.Works with providers to analyze their systems to assist in determination of incompatibilities that may cause claims or other issues between Hudson Health Plan and the provider.







 

3. Ensures that all providers are oriented to Hudson Health Plan policies and procedures and all Department of Health rules and regulations.

 

4.  Provides contracted providers with educational updates on Hudson Health Plan policies and procedures.

 

5.  Assists with claims review as necessary.

 

6. Performs other tasks and functions as directed by management.

 

Qualifications:

 

A minimum of two (2) years of experience in provider relations or claims in a health care organization.  CPT Coding and/or claims processing  experience preferred.  BA or BS in a health related field desired. Valid Driver's license and reliable car required.