PURPOSE OF POSITION:
The purpose of your position is to assist the department supervisor and director with day to day operations within Networks, Credentialing and Contracting Departments. It is expected of the employee to develop, implement and maintain an accurate provider data base; analyze provider data, facilitate the preparation and follow-up of the monthly activities of the Membership Services Committee and PEER committee; track and report provider based information using Department databases; and serve as a communication link with Provider offices and other AultCare Departments regarding the status of providers. Other primary responsibilities include help with various compliance and accreditation standards that are constantly evolving throughout the department. Each person will be assigned a focus area of either membership or credentialing within the department.
A level 2 is an experienced staff that has been a go to for co-workers and can often work independently and complete higher-level work to assist supervisor.
A level 3 is an expert regarding department subject matter, must resolve problems with little assistance consistently assist less experienced staff and oversee processes or staff, as well as pay meticulous attention to detail.
Discount Coordinator responsibilities will include negotiating discounts for high dollar claims, NSA claims and single case agreements. This will be accomplished by maintaining excellent communication skills with providers and the Claims Departments.
RESPONSIBILITES/DUTIES/EXPECTATIONS:
- Maintain a thorough knowledge and meet important industry standards set forth by organizations such as NCQA, CMS, ODI, QHP, CAQH, etc. Helps in coordinating updating of policies and procedures as necessary to comply with these standards.
- Level 2 & 3 will demonstrate a working knowledge of above organizations and experience with processes related to applicable standards. Also will be responsible for maintain reporting for these entities on an ongoing basis.
- Level 3 become subject experts.
- Consistently plans, organizes and completes tasks independently and thoroughly in the allotted time frames ensuring the departments’ day to day work is completed (networks, credentialing and contracting). Subject to frequent interruptions, ability to be flexible when priorities change.
- Level 2 & 3 demonstrates professional development and growth as evidenced by increasing responsibilities and continued success. Actively seeks and pursues opportunities to make a contribution and demonstrates desire for learning. Participates in audits as needed. Coordinates, as well as exercises good judgment in all aspects of workflow within the department. Acquires new knowledge rapidly and is aware of sources for answers to questions.
- Level 3 meet all deadlines, proactively foresee needs of the department, help others prioritize to ensure success and help peers with completion of their tasks as workload allows and requires. Consistently exceeds quality and productivity requirements.
- Supports the day-to-day operations (networks, credentialing and contracting) by making appropriate recommendations to supervisor for changes within the Department, including process improvement and problem solving. Responsible for tracking and reporting own stats.
- Level 2 & 3 regularly have recommended and help coordinate process improvements and problem solving.
- Level 3 shows technical abilities to identify cause and effect. Ability to connect the dots. It is the expectation at this level to understand small scale projects and the cause and effect on the department as a whole as well as the organization.
- Problem solve, handles difficult and sensitive issues with tact; exercises judgment where necessary and consults supervisor on major problems and issues.
- Level 2 & 3 recognize problem areas, have demonstrated higher level thinking in problem solving and handling situations with little or no supervision.
- Level 3 handle complex issues. Ability to remain objective to the viewpoints of others.
- Team player, works across departmental lines while maintaining positive interactions with both internal and external customers.
- Level 2 & 3 display understanding of the organization as a whole, exceptional follow up and follow through. Strong leadership abilities.
- Level 3 displays excellent knowledge of various operations of the organization and is familiar with other departments we interact with regularly and has an understanding of their processes as they connect with our department. Shares resources and information with others.
- Prepare and post follow-up of the monthly activities of the Membership Services Committee and PEER committee (including but not limited to analyses, minutes, summaries, letters, etc.).
- Level 2 & 3 continue to improve analyses and provide meaningful recommendations to supervisor for process improvements specifically related to committees.
- Level 3 coordinate, multitask and prioritize daily work and committee monthly activities without direct supervision.
- Responsible for running queries and reporting. Analyze information to make meaningful recommendations to supervisor.
- Level 2 & 3 assigned specialized/high profile requests.
- Communicates regularly and appropriately with supervisor and co-workers and reports and accurately documents pertinent information.
- Level 2 & 3 coordinate cleanup projects as needed or directed. Recognize trends and provides information/solutions.
- Maintains positive attitude and is cooperative in all duties. Communicates with providers, co-workers, and other health care professionals in a professional and respectful manner.
- Level 2 & 3 always sets a good example, has a positive attitude, takes on additional responsibilities and promotes teamwork within the department.
- Level 3 works effectively with a variety of individuals to accomplish tasks.
- Practices ethical conduct including, honesty, integrity, confidentiality and compliance with policies and procedures.
- Level 2 & 3 demonstrate leadership within the department, including acting as an advocate for your co-workers, Supervisors, Managers, Directors and AultCare.
- Meets acceptable attendance and punctuality expectations (excluding FMLA).
- Seek supervisory guidance/approval as appropriate.
- Level 2 & 3 responsible to provide coverage for co-workers, supervisor or manager as needed.
- Assist with orientation of new personnel into the department.
- Level 2 & 3 will mentor new staff and be instrumental in training. Assists in establishing best practices to ensure accurate and consistent processes.
- Participate in quality review process of department.
- Level 2 & 3 are expected to conduct quality reviews as well as communicate issues and concerns to supervisor.
- Level 3 consistently participates in training and self-development opportunities when appropriate.
- Ability to adapt to new software changes; maintain accuracy of current software, as well as, make suggestions/recommendations for continued streamlining of database and information.
- Level 2 & 3 will be part of project teams for review of new software and developments as well as participate in system testing.
- Promotes and demonstrates professional standards to enhance the development of the department including: portrays professional image, follows dress code, strong organization skills, strong computer skills, strong communication skills, actively seeks and pursues opportunities to make a contribution and demonstrates desire for learning.
- Level 2 & 3 set a good example through a positive attitude and promoting teamwork within the department.
- Level 3 workdays are typically not routine and employee must work both proactively and reactively to department needs to assist supervisor and coworkers as necessary.
- Negotiate one-time discounts with non-participating facilities and providers.
- Settles claims within 30 days to satisfy prompt-pay requirements.
- Develops new relationships with providers where opportunity exists.
- Works with and communicates with claims departments on problems and opportunities.
- Researches or knows average claims costs for procedures across geographic areas.
The above statements reflect the general duties considered necessary to describe the principle functions of the job as identified and are not a detailed description of all the work requirements that may be inherent in this position.
All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, disability, gender identity, sexual orientation or protected veteran status. AultCare is an EEO/AA Employer M/F/Disability/Vet.
AultCare/AHF will provide reasonable accommodations to employees or applicants with disabilities, as defined by the Americans with Disabilities Act, who are otherwise qualified to safely perform the essential functions of the job, with or without accommodation, unless such accommodation would constitute an undue hardship on AultCare/AHF or poses a direct threat to the health and safety of the individual or others that cannot be sufficiently mitigated by reasonable accommodation. Any applicant or employee who requires an accommodation to perform the essential functions of his or her job or to enjoy equal benefits and privileges of employment should notify the AultCare Human Resource Department and request such an accommodation.
QUALIFICATIONS
- Education: High School diploma or GED required, college degree preferred. Experience will be considered.
- Experience: Claims experience desired.
- Able to research information and make decisions.
- Experience or aptitude for negotiating results acceptable to all sides.
- Evidence of varied responsibilities within previous work experience, ability to multi task.
- Maintains current State of Ohio driver’s license.
- Ability to prioritize and meet deadlines.
- Exceptional written and verbal communication skills.
- Must be organized.
- Strong knowledge of Microsoft Office, including Word, Excel, Access, Outlook and PowerPoint.
WORKING CONDITIONS
- Hours: Day Shift, Monday through Friday. Occasional extra hours may be necessary to meet deadlines. Assists in special projects and performs other miscellaneous functions as required.
- Office environment with moderate noise level.
- Frequent sitting, use of hands/fingers across keyboard or mouse, and long periods working at a computer.
- Occasionally walking, standing, twisting/turning and reaching upward or forward during work day
- Use of own vehicle for provider site visits as necessary, mileage will be reimbursed.
