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Optum Payer Relations Specialist in Seattle, Washington

Overview:

The Poly Clinic a part of Optum Care is now offering qualified candidates an opportunity to join our team as a Provider and Payer Relations Specialist . Our company values innovative problem solvers, promotes personal and professional growth and provides a supportive working environment that affords all its employees a healthy work/life balance.

In support of Optum’s mission, vision, and strategic goals, the Eligibility Representative, Lead is responsible for reconciling the more complex eligibility issues and processes. Serves as subject-matter expert and key contact for membership/eligibility issues, data, and reporting. Assumes the role of the lead position in the Eligibility department and provides direct support to the Finance Manager. This position is required to effectively communicate with all the departments within the organization, as well as external areas (e.g., health plans, and contracted vendors).

The Provider and Payer Relations Specialist is responsible leads all external professional relationship management with provider organizations and health insurance company personnel, in addition to internal PCA and PCN boards, leadership, directors and managers. Collaborate with these external organizations to assist in carrying out their goals and objectives. Interface with high level internal/external contacts requiring considerable discretion and initiative.

ESSENTIAL DUTIES & RESPONSIBILITIES

  • Relationship Management

  • Manage communication and relationship collaboration between team members of PCA and PCN, health insurance plans, and provider organizations

  • Administer communication tools with external parties, including owning SharePoint site

  • Responsible for managing issue resolution with clinics by collaborating with clinic administration and PCA and PCN teams

  • Proactively engage providers identifying; educational opportunities that decrease administrative burden, ensure provider compliance to contract terms, and enhance performance

  • Develop and maintain relationship with health insurance personnel to resolve issues and communicate needs to/from the PCA and PCN teams

  • Ensure timely management of issues within the team and communication of priorities.

  • Provide the voice of the clinic administration to PCA and PCN administration

  • Responsible for leading JOC meetings including ensuring attendee invitation and managing attendee lists

  • Manage accurate provider rosters and participating group contact information

  • Correspond with members of physician organizations regarding billing and credentialing needs

  • Work with PCA and PCN team members to develop and deliver interim reports and statistics to physician organizations

  • Provide communication and support for affiliate physician organizations as needed

  • Monitor and deliver on PCA and PCN needs and obligations regarding patients that are outside of signed insurance contracts

  • Understand relationships and referral patterns within territory, contract terms, and reimbursement methodologies

  • When necessary, attend and represent PCA and/or PCN at provider network events and functions

  • Payer Liaison

  • Manage process for maintaining accurate provider enrollment rosters between clinics, payers and PCA and PCN

  • Work directly with Director of Contracting to coordinate contract negotiations and analysis

  • Track, reconcile, and report these provider enrollment lists and attribution differences between health insurance and PCA signed physician organizations

  • Manage attribution information and collaborate with the PCA and PCN teams for follow up: the finance department for needs related to financial forecasting and payment reconciliation, the data analytics team for reporting, and the population health and practice transformation teams for quality improvement needs

  • Analyze, distribute, and monitor payer specific data requests with PCA and PCN provider organizations

  • Liaise with payers to ensure timely transmission of data including claims, enrollment files, baseline and ongoing performance data

  • Network Strategy

  • Execute and support the development of engagement strategies

  • Identify and initiate communication with potential future network participants

  • Contract Maintenance

  • Disseminate, collect, and track all contracts and Business Associate Agreements from all PCA and PCN physician organizations.

  • Monitor deadlines for insurance contracts and addendums.

MINIMUM QUALIFICATIONS

Education: A minimum of college Bachelor’s degree

Experience:

Demonstrated provider relationship management experience with senior level management and personnel.

Prior experience working in the health care industry; either in insurance, medical products, or in the business or marketing department at a provider organization.

Requires prior experience in marketing and/or public relations.

The job description does not constitute a written or implied contract of employment. Optum reserves the right to revise or change job duties and responsibilities as the need arises.

Diversity creates a healthier atmosphere: Optum and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law. Optum and its affiliated medical practices is a drug-free workplace.

Candidates are required to pass a drug test before beginning employment.

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