Sr Account Manager Provider Complaints

The Sr. Account Manager, Provider Complaints is an integral role that successfully manages escalated provider complaints as assigned. Reporting directly to the Sr. Manager, Complaint Resolution, they will be dedicated to (1) expediting the research of formally reported provider complaint (2) contacting providers to negotiate single case agreements and working through the various complaint details and (3) working with the appropriate internal stakeholders to close out all aspects of the complaints. In this role, the Sr. Account Manager, Provider Complaints deals with providers that require one-time resolution as well as serves as a single point of contact for Out of Network providers who have submitted a formal complaint. The Sr. Account Manager will drive results that increase provider satisfaction and reduce/eliminate repeat complaints from assigned providers. Efforts directly impact the improvement of CMS STAR ratings.

Duties & Responsibilities: 

• Serve as internal point of contact for cross-functional internal departments and teams to ensure all provider complaints are addressed and resolved within established guidelines  
• Partners with Sr. Complaint Analyst, and performs root cause analysis, to ensure effective identification of contributing complaint issues 
• Performs all tracking and trending of activity on managing root cause inventory, as well as resolution of all root cause issues identified
• Communicate complaint resolution results to key stakeholders 
• Drafts complex complaint summaries and speaking points to ensure Regulatory can effectively respond to external agencies regarding all aspects of a complaint 
• Makes recommendations on strategy and process improvement to drive successful outcomes of assigned complaints 
• Negotiates complex single case agreements and settlements with complex providers as needed to resolve a complaint 
• Works cross functionally to assist with resolution of complex claims related issues 
• Tracks all aspects of provider complaints and ensures all assigned deadlines are met 
• Serves as a subject matter expert for Delivery System Engagement on resolution of provider complaints
• Additional duties as assigned 

Minimum Qualifications: 

• Network Management / Provider Relations experience with Hospital, Physician, Ancillary and/or Behavioral Health providers  
• Familiarity with reimbursement methodologies (DRG, FFS, Capitation, APG, APC) 
• Experience with resolution of reported provider complaints 
• Managed Care operations experience working with various business partners to facilitate resolution (Legal, Regulatory/Compliance, Claims) 
• Resolution of root cause contributing to provider complaints 
• Work experience with MS Excel, Word, Power Point 
• Bachelor’s Degree from an accredited institution or equivalent work experience 

Preferred Qualifications: 

• Cross functional experience in working