Member and Provider Relations Coordinator - Remote

<strong>At Emergent Holdings, we&rsquo;re creating an innovative environment where our employees belong authentically, contribute meaningfully, and thrive intentionally &mdash; both personally and professionally.</strong>

Southfield, USA

Emergent Holdings

<p class="p1"><strong>Emergent Holdings is driven by a singular goal &mdash; improving the health and safety of our customers and our communities. How do we do that? We create innovative insurance products, technology solutions, and services to support our key stakeholders &mdash; individuals, employers, providers, and strategic partners &mdash; improving the health and safety of the people and places we serve.</strong></p>

keywords: job description,work environment,leadership and facilitation,system and ma knowledge,escalated issues triage and documentation,member and provider outreach,education & experience,knowledge,proficiency,skills


Competitive Compensation and Benefits Package

Overview: <br />This position is responsible for coordinating member and provider outreach and issue resolution for all Covantage JV health insurance plans. Responsibilities for this role include maintaining a detailed understanding of operational systems, managing an inventory of escalated member and provider issues, conducting member and provider outreach and follow-up, preparing for and facilitating provider meetings, or acting as an operations subject matter expert in meetings. The JV Member and Provider Relations Coordinator will be accountable for triaging escalated issues and providing frequent leadership updates. This role will operate as a sole contributor in a very matrixed organization and will need to provide direction to many vendor partners.<br /><br /><br /> <p><strong>WORKING CONDITIONS:</strong></p> <p>Work is performed in an office setting with no unusual hazards. Infrequent travel is required (max 1-2 trips per quarter). Virtual candidates will be considered.</p>
Responsibilities: <br /><strong>Leadership and Facilitation<br /><br /></strong> <ul> <li>Provide routine leadership updates on issue status and resolution</li> <li>Serve as an input to the strategic plan development process</li> <li>Facilitate regular and ad-hoc meetings related to issue remediation</li> </ul> <br /><strong>System and MA Knowledge<br /><br /></strong> <ul> <li>Maintain a detailed understanding of Medicare Advantage regulations surrounding enrollment, claims, customer service, risk adjustment, pharmacy, and medical management operations</li> <li>Maintain proficiency and access to vendor systems for pulling data and conducting analysis</li> </ul> <br /><strong>Escalated Issues Triage and Documentation<br /><br /></strong> <ul> <li>Maintain internal triage rosters across JV&rsquo;s</li> <li>Manage master issues log and updates to the log</li> <li>Develop and regularly update routine issue reporting and issue driver reporting</li> <li>Create executive-level presentations for providing updates on critical issues</li> </ul> <br /><strong>Member and Provider Outreach<br /><br /></strong> <ul> <li>Conduct direct member outreach to resolve and follow-up on complex issues</li> <li>Partner with Provider Relations team to help resolve claims issues or other provider inquiries</li> <li>Provide support and training to local Provider Relations teams directly, enabling them to handle issues on their own</li> </ul>
Requirements: <br /> <p><strong>EDUCATION OR EQUIVALENT EXPERIENCE:</strong></p> <ul> <li>Bachelor&rsquo;s degree in business or health-related field.</li> <li>Combinations of relevant education, certifications, and experience may be considered in lieu of a degree.</li> <li>Continuous learning, as defined by the Company&rsquo;s learning philosophy, is required.</li> <li>Certification or progress toward certification is highly preferred and encouraged.</li> </ul> <br /> <p><strong>EXPERIENCE:</strong></p> <ul> <li>Five years of relevant business experience required.</li> <li>Prefer candidates with direct customer service or provider relations experience.</li> </ul> <br /> <p><strong>SKILLS/KNOWLEDGE/ABILITIES (SKA) REQUIRED:</strong></p> <ul> <li>Has knowledge of CMS rules and guidance regarding MA product characteristics and administration.</li> <li>Has knowledge of and considers system and operational capabilities and constraints when proposing benefit changes.&nbsp;</li> <li>Knowledge of all product/benefits information used in MA member communications, sales, marketing, training, system configuration &amp; CMS attestations.</li> <li>Ability to successfully collaborate with multiple operational areas (compliance, communications, sales, marketing, Actuarial services, finance, claims configuration, G&amp;A, network contracting, Part D, care management, etc.).&nbsp;</li> <li>Knowledge of Original Medicare and MA required.</li> <li>Knowledge of project management concepts and the ability to organize work into a detailed plan.</li> <li>Ability to work effectively in a team environment.</li> <li>Organizational, planning, analytical, presentation and communication skills.</li> <li>Leadership and/or analytical experience with data, systems, and operations.</li> <li>Ability to work with moderate supervision to analyze complex problems. Utilizes a variety of resources to find information and synthesize solutions.</li> <li>Knowledge of claim coding, submission, and adjudication</li> <li>Knowledge of CMS guidance regarding product and benefit design and administration</li> <li>Knowledge of Original Medicare rules and benefits</li> <li>Understanding of Medicare Part-D benefits.</li> </ul>