DEPARTMENT: Provider Relations
POSITION SUMMARY:
The provider relations (PR) quality review specialist is responsible for ensuring the credentialing and provider management database (CACTUS) contains accurate and up-to-date provider information and that provider data contained within that database is properly reflected in all member and provider resources, including print copies of provider directories and online provider search tools.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
- Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards and sensitivity to confidential information.
- Responsible for auditing and/or monitoring provider data in CACTUS and UPHP’s claims processing system to ensure provider data is entered and updated accurately, timely and in accordance with credentialing policies.
- Ensures data maintained in CACTUS database is entered consistently among all staff. Identifies inconsistencies and coordinates data revision through clear instruction to staff.
- Ensures network providers meet Medicaid and Medicare eligibility and enrollment requirements, including, but not limited to, CHAMPS enrollment, Medicare eligibility requirements and Medicare preclusion list.
- Responsible for development, maintenance and oversight of print provider directories applicable to all product lines, in compliance with model documents and guidance prepared by the Centers for Medicare and Medicaid Services (CMS), the State of Michigan Department of Health and Human Services (MDHHS) and the National Committee for Quality Assurance (NCQA). Ensures print provider directories are updated in a timely manner in compliance with applicable requirements.
- Responsible for maintenance and oversight of web-based provider directories and search tools applicable to all product lines, in compliance with guidance prepared by CMS, MDHHS and NCQA.
- Evaluates physician directories at least annually to ensure accuracy of office locations and phone numbers, hospital affiliations, accepting new patients, awareness of network participation and other data as required. Identifies opportunities and takes action to improve the accuracy of the information in physician directories.
- Evaluates web-based provider directories for understandability and usefulness to members and prospective members at least every three years including, but not limited to, reading level, intuitive content organization, ease of navigation and additional languages if applicable.
- Supports quality management and company-wide quality initiatives such as Healthcare Effectiveness Data and Information Set (HEDIS®), Consumer Assessment of Health Plans (CAHPS) and NCQA.
- Creates reports to evaluate and monitor member access and availability and to fulfill network adequacy requirements for all product lines.
- Maintains confidentiality of client data.
- Performs other related duties as assigned or requested.
POSITION QUALIFICATIONS:
Education:
Minimum:
Associate degree in health information processing or related field.
Preferred:
Bachelor’s degree in business, health information processing, health information systems or related field.
Experience:
Minimum:
One year of experience in managed-care or related health-care setting
Preferred:
Experience in managing provider demographic data and experience with the CACTUS database
Required Skills:
Working knowledge of Microsoft Office (Word, Excel, Outlook, Access)
Keyboarding proficiency
Excellent human relation and oral/written communication
Excellent organizational and prioritization abilities
Desired Skills:
Knowledge of MS PowerPoint
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
- Ability to access departmental files
- Ability to enter and access information from a computer
- Ability to access all areas of the UPHP offices
- Moderate physical effort (lift/carry up to 25 pounds)
- Occasionally lifts supplies/equipment
- Occasional reaching, stooping, bending, kneeling, crouching
- Prolonged periods of sitting
- Occasional prolonged standing
- Manual dexterity and mobility
Working Conditions:
- Works in office conditions, but occasional travel may be required
- Exposure to situations requiring exceptional interpersonal skills or periods of intense concentration
- Subject to many interruptions
- Occasionally subjected to irregular hours
