Job Description: PROVIDER NETWORK SPECIALIST at UNM Hospital

Department: Provider Network Development

FTE: 1.00
Full Time
Shift: Days

Position Summary:
Manage negotiation, operation, and administration of liaison activities associated with healthcare provider contracting for the TriWest Veteran Administration (VA) Community Care Network (CCN) for the state of New Mexico. Develop and deliver provider education for participant facilities and individual physicians, in compliance with CCN program requirements, and conduct research into claims, referral and authorization, and other operational issues related to provider contracting and networking. Ensure adherence to Hospitals and departmental policies and procedures. No patient care assignment.

Detailed responsibilities:
* NETWORK RELATIONS - Manage the negotiation of individual network contracts with hospitals, physician groups, and other health care related agencies and companies in New Mexico and West Texas
* NETWORK RELATIONS - Manage negotiation of various contract rates and reimbursement methodologies for all network agreements, ensuring compliance with the VA, TriWest, Medicare, or industry regulations, as appropriate
* NETWORK RELATIONS - Oversee the negotiation and establishment of contract language and legal requirements in compliance with VA and Triwest requirements, University policies, industry standards and other Federal laws and regulations
* NETWORK RELATIONS - Serve as primary interface and liaison with TriWest CCN network administration, management, and staff, as needed to execute contracts, resolve contractual problems and issues, and provide information and instruction
* NETWORK RELATIONS - Plan, develop, and deliver education programs for network entities on all aspects of CCN requirements, to include program administrative guidelines, operational processes, billing, credentialing and certification, and related issues
* RESOURCE - Serves as primary operational liaison with the TriWest Corporation; independently oversee key operational activities between NM Providers and Triwest, to include referral and authorization operations, claims adjudication, educational activities, and planning for network providers to meet VA staffing requirements
* PROCESS IMPROVEMENT- Research and assess CCN network needs and develop strategies to meet network operational requirements and goals; analyze issues such as provider and coverage needs and data access standards in support of contracting and network development strategies
* ISSUE RESOLUTION - Provide oversight and primary liaison services between CCN network providers and the identified claims payment administrator for the program; identify claims payment issues and/or trends and coordinate resolution of problems and issues with the payer
* ISSUE RESOLUTION - Represent network entities in individual discussions with the claims payment administrator and TriWest; analyze Explanation of Benefits documents received from the administrator and/or Medicare, and resolve individual payment problems and issues, as they arise
* OTHER - Perform miscellaneous job-related duties as assigned
* COMMUNICATIONS – Maintain and update all provider and institutional contract and credentialing application documents; create and share spreadsheets for tracking current contracting statuses; plan, develop, implement and update the UNMH CCN internet web page, including links for provider resources
* DEVELOPMENT - Enhance professional growth and development through participation in educational programs, reading current literature, attending in-services, meetings and workshops

Qualifications

Education:
Essential:
* Bachelor's Degree
Education specialization:
Essential:
* Related Discipline

Experience:
Essential:
3 years directly related experience

Nonessential:
No preferred experience

Credentials:
Essential:
* Not Applicable/Not Required

Physical Conditions:
Sedentary Work: Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.

Working conditions:
Essential:
* No or min hazard, physical risk, office environment