Health Insurance Provider Relations Representative Ii

Let’s do great things, together​​​​​Founded in Oregon in 1955, Moda is proud to be a company of real people committed to quality. Today, like then, we’re focused on building a better future for healthcare. That starts by offering outstanding coverage to our members, compassionate support to our community and comprehensive benefits to our employees. It keeps going by connecting with neighbors to create healthy spaces and places, together.
Provide exceptional customer service to contracted providers by being the liaison between the contracted provider and the Health Plan. The Provider Relations Representative is responsible for presenting, promoting, and resolving concerns and issues brought forward by the providers or the Health Plan.​This is a Hybrid role for the Portland Metro Area. Please fill out an application on our company page, linked below, to be considered for this position.

• ​​​​https://j.brt.mv/jb.do?reqGK=27714768&refresh=true

Benefits:

1. Medical, Dental, Pharmacy, and Vision Coverage
2. 401K
3. FSA
4. PTO and Paid Holidays

Required Skills, Experience, & Education:

1. College degree or equivalent work experience in the Health Insurance industry
2. 2-4 years’ experience as a Provider Relations Rep with a Health Plan or 2-4 years’ experience as a Provider Relations Rep I with Moda.
3. Strong facilitation skills with an ability to run provider meetings with prioritized specific topic agendas reflecting entire provider support.
4. Strong relationship building skills.
5. Demonstrated strong verbal, written, and interpersonal communication skills.
6. Possess analytical, problem-solving, and attention-to-detail skills.
7. Knowledge of medical insurance reimbursement methodologies including but not limited to DRG and APC pricing.
8. PC proficiency, preferably with Microsoft Word and Excel and FACETS.
9. Ability to work well under pressure, work with frequent interruptions and shifting priorities.
10. Maintain confidentiality and project a professional business image.
11. Identify root causes of claim problems and trends while participating in the development of potential solutions.
12. Strong ability to work within a team environment as well as independently.

Primary Functions:

1. Identify root cause of claims problems, trends, and participate in developing solutions. This includes performing research through available systems, policies and departments ensuring timely resolution.
2. Develop and review Dashboard metrics (quality, financial, triple AIM) and translate into actionable items based on group specifics.
3. Ability to provide actionable financial and operational data and to ensure action plans are implemented to achieve performance goals.
4. Work in a consultative role with various departments locally creating effective information and analyses to optimize the market’s strategic objectives for providers.
5. Provide timely responses to all provider inquiries, within in three business days.
6. Conduct regular on-site provider visits to create strategic provider partnerships to improve health efficiencies, and foster provider experience while ensuring cohesion across product lines with Moda’s policies. All providers should be provided with an invitation for such on-site visits. There should be a minimum of 36 visits on average per year (three per month).
7. Educate providers on their health plan contract language ensuring consistent interpretation.
8. Organize, prepare, and present annual Provider Workshops. Workshops are our opportunity to foster relationships, provide education and represent Moda in a positive light.
9. Participate in ongoing Moda committees with the expectation of providing feedback and recommendations from the Provider Relations perspective while bringing back pertinent information.
10. Utilize necessary resources, tools and navigate systems efficiently to provide accurate and timely responses to inquiries
11. Represent Moda in a positive and professional manner at all times.
12. Collaborate with other teams, peers, and management to identify areas of inefficiency and process improvement opportunities.
13. Other duties as assigned

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