Resp & Qualifications
PLEASE NOTE: Based on qualifications, education, and experience preferred candidate may be hired at the Senior level.
PURPOSE: This position is primarily responsible for working with CareFirst Patient Centered Medical Home (PCMH) providers and the PCMH Administration team in the PCMH program. The incumbent is responsible for managing a specific geographical territory at CareFirst. They respond to PCMH provider inquiries with independent analysis, escalation, if needed, and the preparation of detailed responses within specific timeframes. The incumbent must have knowledge of the PCMH and Total Care and Cost Improvement (TCCI) Programs, and the policies and procedures developed for those programs, as well as CareFirst systems, products, medical policy, contracting and regulations. They support the Provider Relations Department and corporate efforts to ensure continuous improvement to their job knowledge, quality and overall productivity to improve provider satisfaction.
The purpose of the Provider Relations Department is to exceed provider satisfaction and provide Service Excellence for all CareFirst contracted physicians, providers, hospitals and ancillary providers. This includes providing education and training in multiple settings, complex claims resolution and extensive knowledge of CareFirst Corporate Initiatives and special projects and programs. The Provider Relations’ Associates are advocates for the provider community and training ambassadors for CareFirst’s general policies, procedures and internal business processes as well as PCMH and TCCI policies described in The PCMH Program Description and Guidelines. The PCMH Program Rep is responsible for face-to-face onsite interactions with PCMH providers and Multi-Panel PCMH provider groups
Under the general guidance of the Manager, the PCMH Program Provider Representative’s accountabilities include, but are not limited to, the following:
PCMH Program Management, Education and Training
- Maintain extensive knowledge of PCMH Program Description and Guidelines, Provider Relations Provider Manual, PCMH policies and procedures, for professional providers. Extensive knowledge of CareFirst platforms, professional provider contracts and all lines of business.
- Partner with the Center for Provider Education and Training to develop training presentations, webinars and seminars for PCMH providers.
- Respond to PCMH inquiries via face to face visit, correspondence, e-mail, phone, etc. within 48 hours with appropriate follow up/through
- Maintain list of Tier 1 contacts/visits by region and ensure quarterly outreach/operational meetings are held.
- Provide on-site provider training, seminars, webinars, targeted and specialized training and technical training for online tools, Voice Response Unit and Provider Self Service (PSS) and other CareFirst initiatives.
- Ensure that new provider visits and training is arranged and facilitated within 30 days of receipt.
- Develop content for presentations/seminar/conference
- Conduct In-service Training Visits based on provider needs.
Visit Types: PCMH Portal Access Training for new PCMH Providers; refresher PCMH Portal Access training; new provider training, including, but not limited to CareFirst Direct training; PSS Portal training and training for new CareFirst products and services. Other visits, conference calls and/or or meetings including, but not limited to: CEO PCMH Town Hall meetings; PCMH Outcome Incentive Review meetings and other educational and training sessions that may be held by PCMH Administration Team, Regional Care Directors (RCDs) or Provider Relations Management team.
- Assist in training new PCMH Program Provider Representatives, Analysts and Local Care Coordinators (LCC).
- Maintain Portal Administrator quality assurance and ensure portal administrators are appropriately trained on the CareFirst provider portal (iCentric).
- Train, monitor and assist PCMH providers in utilizing the CareFirst Provider Self Service (PSS) portal tool to ensure that accurate provider files are maintained, monitored and assure that the PSS tool is utilized according to established timeframes.
- Provide refresher training on all CareFirst products or services, as needed.
- Develop reports and create for management reports and status updates for all education and training conducted.
- Work closely to train RCD/Practice Consultant teams on any internal CareFirst initiatives and programs.
- Develop quarterly electronic newsletter targeted to PCMH primary care providers; manage distribution list and ensure legal review.
- Lead quarterly regional audits of panel assignments/functions to include Portal Admin and Designated Physician Representative.Support of PCMH RCC/PC team acting as liaison for all PCMH-networks management related inquiries.
Physician Recruitment, Project Management, Corporate Initiatives and Special Projects
- Provide research, analytic and resolution support for Corporate Initiatives, specifically PCMH, TCCI, HEDIS, EDI/EFT and other Special Projects.
- Recruit and retain physicians into special programs/projects as defined.
- Participate in special departmental or corporate projects or initiatives, provides coverage for team members or representatives when necessary and represent team on projects.
- Promotes atmosphere of teamwork among all teams and ensure appropriate interactions, offers of assistance and willingness to take on task. Participation and completion of assigned projects within specified times. Represents team in meetings, assist with special and corporate projects and covers for team members when necessary.
- Represent PCMH Program Provider Team and/or Manager/Supervisor in internal and external meetings and workgroups.
- Contributes to the oversight of special projects and data interfacing with PI&C.
- Contributes to the recruitment and support efforts for increasing and engaging participation in the in the PCMH Program as well as other programs (Common Model, FigMd, PCMH Plus, etc.) to include report preparation for management.
- Contributes to special Projects as assigned to PCMH Provider Relations. Regularly interface with Credentialing, Medical Policy, Contracting, Provider Service, Claims, and other departments within CareFirst seeking resolution to provider problems.
Business Support/Complex Claims/Case Resolution
- Work independently to provide research, analytic and resolution support on special cases and projects ensuring that all CareFirst policies and contractual guidelines are clearly identified as required by the case.
- Provide verbal or written responses to inquiries to management and other internal and external customers.
- Acts as a primary resource for PCMH Representatives and provides needed assistance to providers in resolving escalated service related issues and timely response to provider inquiries via face to face visit, correspondence, e-mail, phone, etc.
- Coordinate escalated claims disputes and conducts all necessary research timely and effectively along with the ability to analyze and resolve root cause issues.
- Initiate escalated claims resolution process
- Interface with RCD, PC, PCMHOps, Credentialing, Medical Affairs, Contracting, Provider Service, Claims, and other departments within CareFirst seeking resolution to provider problems.
- Participate in claims/policy/procedural meetings and other trainings as requested with providers as outlined below.
- Monthly Review of Cumulative Report
- Perform a monthly review of the cumulative report for additions, deletions, updates and take responsibility for accuracy of data
- Contact all new practices and schedule visits/portal admin. Within 30 days.
- Complete administrative responsibilities, such as, expense reports, calendar updates, meeting summaries, etc. as directed and in a timely manner.
- Holds and maintains working relationship with key Health Systems, PCMH providers, Multi-Panel PCMH groups and Patient Account Managers representing PCMH providers.
- Provides ongoing teamwork and partnership with PCMH Operations and RCC teams to train PCMH providers on accessing PCMH Provider Portal, monitoring and maintaining that access.
- Work closely with PCMH Provider’s designated office staff.
- Build and maintain appropriate relationship with providers by ensuring regular communications and timely problem resolution
- Leverages provider relationships to drive and influence provider behavior towards favorable outcomes
- Proactively identifies provider needs and responds appropriately through complex problem solving, engagement of other internal or external resources, and providing high level service
- Maintains a high level of customer satisfaction and service excellence with the provider community while driving the initiatives of the department
- Develop relationships with RCDs/PCs
- Bachelor’s Degree in public health, business or communications is preferred. In lieu of Bachelor’s Degree, must have 4 years relevant experience in the health care industry, including project management experience with providers, training, customer service and presentations.
In addition to the above:
- Minimum of 3 years of experience in Provider Relations with a solid understanding of the PCMH provider type.
- Experience supporting physician recruitment efforts, large-scale project management and vendor relationship management.
- A car is essential to travel within state and surrounding areas. Travel out of office at least 3 days/week.
- Working knowledge of CMS 1500 or CMS 04 and CPT coding.
- Working knowledge of Microsoft Excel, Microsoft Access, Microsoft PowerPoint and Microsoft Word.
- Must be able to provide detailed analysis and reports as needed to management
- Thorough knowledge of managed care industry legislated and regulated requirement, health care financial matters and third-party payment methodologies.
- Understanding of contractual documents and ability to effectively communicate terms to providers.
- Ability to work independently with minimal management oversight.
- Build and maintain relationships within the company and within the provider community.
- Strong interpersonal, written and verbal communication skills, including presentation skills.
- Ability to work independently with minimal supervision and as part of a team.
- Ability to manage competing priorities, responsibilities and projects to meet specific deadlines.
- Strong analytical skills, research and problem-solving abilities.
- Sound organizational and time management skills.
- Considerable judgment, tact, initiative, accuracy in work and trustworthiness.
- Proficiency in computer software applications.
- Must be able to effectively work in a fast-paced matrix environment with frequently changing priorities, deadlines, and workloads that can be variable for long periods of time.
- Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
- Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
- Proficient in computer applications as noted above as well as Facets, FEP, and NASCO
- Working knowledge of the provider community, CareFirst Medical policy, coding, contracts, multiple reimbursement methodologies, medical terminology, and provider specialties.
- Direct experience with training and education of CareFirst policies, procedures, systems, claims and appeals policies in addition to exhibiting a proven ability to use the ECRP and SAU process for escalation of claims.
Department: Provider Relations - PCMH I
Equal Employment Opportunity
CareFirst BlueCross BlueShield is an Equal Opportunity (EEO) employer. It is the policy of the Company to provide equal employment opportunities to all qualified applicants without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, age, protected veteran or disabled status, or genetic information.
Hire Range Disclaimer
Actual salary will be based on relevant job experience and work history.
Where To Apply
Please visit our website to apply: www.carefirst.com/careers
Please apply before: 6/15/2018
Federal Disc/Physical Demand
Note: The incumbent is required to immediately disclose any debarment, exclusion, or other event that makes him/her ineligible to perform work directly or indirectly on Federal health care programs.
The associate is primarily seated while performing the duties of the position. Occasional walking or standing is required. The hands are regularly used to write, type, key and handle or feel small controls and objects. The associate must frequently talk and hear. Weights of up to 25 pounds are occasionally lifted. The associate must be capable of travel outside the office via personal vehicle.
Sponsorship in US
Must be eligible to work in the U.S. without Sponsorship