Job Description
This position is located in Modesto and there is an initial training period where being in the office everyday is required. Then the role is hybrid.
Overview:
Under specific supervision, analyzes, reviews, and processes referrals for authorization of outside medical services. Referral types and specialties are limited, follow minimal referral protocols, and/or require reasonable level of supervisor directions. Researches and resolves inquiries from outside providers, members, physicians, outside providers and staff regarding specific authorizations with reasonable level of supervisor directions. Updates and edits authorization in the Outside Medical Services system. Participates in changes/additions to enhance service levels and efficiencies. Job Summary:
Supports the growth of provider networks by researching and developing partnerships to fill service gaps or decrease costs. Contributes to provider satisfaction by collaborating and/or creating training materials to aid provider education and consulting on issues as they arise. Documents and organizes data for assessing network performance and develops knowledge around contract and regulatory compliance including network adequacy, claims, disputes, and/or provider directories. Supports contract strategy network development by engaging in collaborative workgroups to ensure provider strategies improve access to patient care. Supports continuous improvement efforts by organizing data and/or engaging in the implementation of continuous improvement efforts to aid providers and business goals. Essential Responsibilities:
Pursues effective relationships with others by proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome. Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team. Supports continuous improvement efforts by:
organizing provider, claims, and contracting data to assist the team in identifying and/or consulting on continuous improvement opportunities across the contract ecosystem (e.g., identifying business and operational disparities between organizational and provider expectations, constraints, and risks to accessible care, building and maintaining relationships); engaging in the implementation of process improvement initiatives to aid providers and business goals; and may also include supporting standard and non-standard analyses of provider and market data to develop recommendations for improvement initiatives. Ensures contract commitments are met by: organizing provider data in appropriate data platforms and supporting the consultation of provider compliance; documenting provider activities and/or supporting the collaboration with alternate stakeholders to ensure compliance with contract terms and conditions; and following guidelines to ensure provider compliance with state and federal regulations as well as KP policies and procedures. Supports contract strategy development by:
executing tasks to support strategies that improve access to patient care while managing outside service costs, with minimal supervision; collaborating with team members to provide consultation on local service delivery planning to aid in the achievement of provider priorities and strategies; engaging in collaborative cross-functional workgroups and/or executing on strategies to meet the unique needs of diverse stakeholders; and participating in and/or beginning to conduct peer training for new hires and contingent workers (e.g., establishing contract language, determining payment rate parameters, defining workflow and business processes, and ensuring cross-training across all service lines). Supports the growth of the Provider Network by: researching and evaluating potential partners/alliances for assigned service area to fill service gaps or decrease costs in current service offerings; developing trusting relationships with providers to understand their role in the external network; serving as a liaison between providers and KP by completing communication tasks independently (e.g., contract compliance such as access, availability, referral operations, and/or supporting member complaints); and supporting provider site visits, daily interactions, and ad hoc meetings by organizing components of itineraries and agendas, gathering credentialing materials, and/or supporting the initiation of this process. Contributes to provider satisfaction by:
using comprehensive foundational knowledge of provider/contract operations to consult on issues that arise from contract configuration/interpretation and/or related to claims/disputes, billing, payment, reimbursement, other operational issues, and/or directories; contributing to tasks to ensure requests for information, questions, and problems are identified, documented, and addressed in a timely manner; and creating training materials to aid provider education and orientation on health plan systems, processes, and/or credentialing. Qualifications:
Knowledge, Skills and Abilities:
(Core) Ambiguity/Uncertainty Management Attention to Detail Business Knowledge Communication Critical Thinking Cross-Group Collaboration Decision Making Dependability Diversity, Equity, and Inclusion Support Drives Results Facilitation Skills Health Care Industry Influencing Others Integrity Learning Agility Organizational Savvy Problem Solving Short- and Long-term Learning & Recall Teamwork Topic-Specific Communication Knowledge, Skills and Abilities:
(Functional) Business Relationship Management Compliance Management Computer Literacy Health Care Reimbursement Interpersonal Skills Presentation Skills Quality Assurance Process Time Management Trend Analysis Written Communication Minimum Qualifications:
High School Diploma or GED AND Minimum five (5) years of experience in health care delivery or operations in a managed care environment, customer relationship management, or a directly related field. Preferred Qualifications:
Project Management Professional (PMP) or equivalent project/program management certification. Two (2) years of project management and/or process improvement experience.
