Health Plans, Network Services Representative

Overview

As a patient-focused organization, University of Utah Health exists to enhance the health and well-being of people through patient care, research and education. Success in this mission requires a culture of collaboration, excellence, leadership, and respect. University of Utah Health seeks staff that are committed to the values of compassion, collaboration, innovation, responsibility, belonging, integrity, quality and trust that are integral to our mission. EO/AA

• This position is responsible for daily interaction with internal departments as well as conversations with the Provider Network. It requires frequent travel to Providers’ offices where it negotiates contracts or letters of agreements, as well as deals with provider issues and concerns. This position writes draft contracts, amendments, letters of agreement, provider correspondence and other documents as necessary. It is responsible for financial performance within an assigned service area.

Corporate Overview: University of Utah Health is an integrated academic healthcare system with five hospitals including a level 1 trauma center, eleven community health centers, over 1,600 providers, and a health plan serving over 200,000 members. University of Utah Health is nationally ranked and recognized for our academic research, quality standards and overall patient experience. In addition to our clinical delivery system, we have a School of Medicine, School of Dentistry, College of Nursing, College of Pharmacy, and College of Health providing education and training for over 1,250 providers annually. We have over 2 million patient visits annually and research grants exceeding $350 million. University of Utah Hospitals and Clinics represents our clinical operations for the larger health system.

Responsibilities

• Establishes professional and effective face-to-face, written, and telephone communication relationships with assigned providers.
• Travels to provider and facility locations to identify, discuss, and resolve various issues, responds to provider requests for research and resolution of complaints.
• Disseminates/communicates information to internal colleagues and communicates significant or important information to appropriate departments.
• Interacts with Reimbursement Services regarding payment schedules and rates of reimbursement.
• Performs initial orientation and ongoing in-service/education to providers.
• Informs providers of policy changes and/or new policies.
• Ensures providers are following proper medical procedure and referral, information/authorization, covered service guidelines, and submission of claims.
• Assists in establishing financial and quality targets for medical expenses within the assigned service area and the ongoing monitoring and educating of providers who are not satisfying such targets.
• Collaborates with assigned providers to close gaps in care and to improve member satisfaction.
• Builds relationships of trust with providers through timely follow through and through a customer service focus.
• Completes department initiatives that relate to assigned providers.
• Initiates, coordinates, and negotiates contracts with physicians, hospitals, and ancillary in an assigned area to assure adequate medical services for Health Choice members. Maintains and ensures provider demographic information is complete and up to date.
• Analyzes and evaluates network coverage to identify network needs.
• Reviews contracts and proposals to determine proper reimbursement.
• Obtains required information and documents from providers to begin the credentialing process.
• Identifies and submits updates and corrections to demographics as they are identified or as received from the provider.
• Analyzes network coverage to identify network needs.
• Contracts and proposals are submitted to providers and reviewed. Acceptable reimbursement parameters are determined with management prior to execution of the contract.
• Assists with applicable accreditation organization and regulatory compliance responsibilities.

Knowledge / Skills / Abilities

• Strong organizational skills.

• Strong presentation and oral and written communication skills.

• Proficient ability to use Microsoft Office products include Excel and Word.

• Ability to negotiate and implement provider contracts.

• Strong customer service skills and techniques.

• Ability to plan and organize.

Qualifications

Qualifications

Required

• Associate's degree or equivalency.
• Two years experience in a health plan or health care environment.

Qualifications (Preferred)

Preferred

• Experience with Medicare