Provider Operations Service Representative (Hybrid/Troy, MI) - Health Alliance Plan

GENERAL SUMMARY: 

The role will serve as primary contact for providers for education and training with HAP operations. PSA will develop positive and supportive relationships with affiliated providers, to include physician/hospital organizations, primary care physicians, specialty care physicians and ancillary providers.  PSA will improve provider compliance with HAP policies and procedures while providing support to providers and assist them in becoming HAP advocates by improving practice operations, productivity, patient satisfaction, and performance improvement in the areas of quality, utilization, and risk adjustment. 

DUTIES AND RESPONSIBILITIES:

• Conduct telephonic and in-person educational sessions and physician office staff orientations with providers (physicians, office staff, hospital staff, ancillary providers, and hospital/network administrators).

• Educate providers about HAP programs and operations including:

  • HAP products and lines of business

  • Claims, referral, and eligibility verification processes

  • Referral/authorization guidelines and system training

  • HAP provider portal training

  • Performance improvement opportunities in the areas of quality, utilization, risk adjustment, and cost

  • Regulatory standards required by CMS, NCQA, MDHHS, etc.

  • Disease and medical management programs

  • Utilization management guidelines

  • HAP and network policies and procedures including updates

  • Contracting and credentialing processes

• Assist in the development, implementation and communication of policies and procedures required by HAP, NCQA, CMS, and MDHHS to ensure quality health care and efficient managed care operations in a provider setting.

• Assist providers with interpretation of HAP’s provider data reports.  Help providers to obtain additional reports to support utilization and/or medical management, as needed.

• Serve as an ombudsperson for providers, offering to resolve challenges or concerns at the provider site, or by communicating problems to the appropriate HAP staff. 

• Develop and communicate an understanding of financial performance issues, provider profiling, and other related matters that impact provider behaviors.

• Develop and communicate an understanding of HAP Medical Management functions and processes, including management of utilization, quality, and care.

• Develop and maintain effective relationships with network administrators.

• Assist in the coordination and presentation of provider conferences, workshops, and orientations.

• Represent Provider Network Management department in internal workgroups.

• Represent Provider Network Management department and HAP in network joint operating committee meetings; collaborate with Senior Provider Service Administrators to facilitate, prepare materials, and follow-ups for joint operating committee meetings.

• May require significant travel within Michigan.