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Payor/Provider Relations Specialist

Sixteenth Street Community Health Centers
United States, Wisconsin, Milwaukee
1337 South Cesar E Chavez Drive (Show on map)
Mar 20, 2025
Join our team which is committed to the delivery of the highest quality healthcare service. We are seeking a full-time Payor/Provider Relations Specialist who is self-motivated, energetic, and a take-charge individual. Job Summary: The Payor/Provider Relations Specialist is the liaison between the clinic providers/offices and insurance companies to ensure providers are properly established with insurance companies. He/she is also responsible for managing relationships with payers and will manage the regional contract inventory overall. This includes maintaining a shared database with key contract terms and providing accurate and thorough information regarding fee schedules and implementation, product and product changes, and contract measures and metrics. Additionally, you will be responsible for the resolution of questions or concerns from/to payers as well as for internal constituents through operations support and submission of provider credentialing/re-credentialing applications. Responsibilities: Key facilitator for regular payer market relationship meetings to focus on administrative, transactional, and operational, items including policy changes, claim payment/AR issues, etc. Manages and is accountable for the timely and appropriate resolution of payer and/or provider issues. Prepare materials and files necessary to comply with external audits by payors and/or governmental agencies. Maintain accurate insurance directories. Audit health plan directories for current and accurate provider information. Disseminate new/modified professional information to health plans. Monitors identified access barriers, billing, and reimbursement trends. Keeps staff and physicians apprised of developments in the managed care marketplace. Maintains and distributes participation information for all contracts to key staff. Responsible for engaging leadership in strategic issues resulting from meetings, and discussions. Work cross functionally across key departments to ensure health plans are compliant with rate loading and other operational terms in accordance with contract effective date. Under the guidance of the CFO, ensure that contracts are properly reviewed, executed, and uploaded into the contract database and internal files. Analyzes and monitors financial aspects of existing managed care contracts. Utilizes analysis to provide recommendations on contract renewals, renegotiations, or termination. Ensure new contract terms (including payment terms) for payer agreements are successfully communicated within the organization. Coordinates the communication of fee schedules with business office and other departments in the organization as needed. Educates internal and external parties as needed to ensure compliance with contract policies and procedures. Lead the provider-insurance credentialing process. Responsible for all aspects of insurance (private and public) credentialing and re-credentialing of providers, to include but not limited to verification of application/documents, mailing of requests for consideration, initial applications, approval, denial, termination letters, and accurately loading provider information in the Credentialing database. Follow up with insurers and doctors to accelerate credentialing process timing to ensure smooth on-boarding of new doctors. Review credentialing files and work with providers to obtain any missing, incomplete, or expiring information. Inform management of credentialing statuses. Improve processes to streamline and optimize credentialing process. Serve as the point of contact for providers to give updates on credentialing status. Qualifications: Bachelor's degree preferred, in lieu of degree will consider experience. Proficient in using the Microsoft Office software applications (Excel, Word, PowerPoint). Strong communication skills and ability to formally present information (Visio, PowerPoint) in a clear, concise, and persuasive manner to the leadership team. Well defined communication skills and a demonstrated aptitude for communicating with both business users and technical staff. Meticulous attention to detail. Strong interpersonal, problem solving and relationship building skills. Team-first attitude and a positive demeanor. Credentialing experience preferred.