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Medicare Provider Relations Representative (Network Operations Senior Analyst)- Work at Home-TX, Houston, Texas

Job typeFull Time
CountryUnited States
General Summary: This individual reports directly to the Network Operations Manager and will develop and maintain positive relationships with physicians and other provider types within the provider network. Will also support the activities of the Network Operations Department, including: negotiating contracts and single case agreements, assisting and supporting the contractual and operational relationship with providers, coordinating provider databases, credentialing, resolution of claims and appeals; assisting with the analysis of financial, medical cost trends for providers.

Coverage Area: Texas/Oklahoma; Medicare licensed service areas
Candidate must be located in Texas, preferably Houston, TX area

Essential Duties and Responsibilities

Contracting and Credentialing Support
  • Assist in coordinating provider agreements, amendments and letters of agreement with non-contracted providers as needed by Manager
  • Ensure copies of executed contracts or correspondence are returned to providers
  • Prepare contract packages, agreements and amendments for mailing to potential providers
  • Coordinate, track and ensure credentialing process is complete for providers
  • Maintain provider master files and online databases

Coordinate Load Forms and Maintain Provider Data Bases
  • Complete and maintain departmental activity log
  • Complete and load contract changes and rate terms for providers in TractManager and QNXT
  • Assist in coordination of collection, compilation and maintenance of data for HSD tables for internal, state and CMS audits as well as any GEO Access Mapping
  • Auditing of rate and demographic data to ensure system accuracy

Provider Orientations and Operational Meetings
  • Organizes and conducts operating committee meetings with providers to include education on contracts, policies and procedures, financial trends and collaboration opportunities
  • Gather operational concerns expressed at operational meetings and work with Manager to resolve any operational issues
  • Initiates and maintains effective channels of communication with providers, office staff and matrix partners

Resolution of Claims and Operational issues with Providers
  • Assists in resolving elevated and complex provider service complaints. Researches problems and negotiates with internal/external partners/customers to resolve escalated and sensitive issues
  • Research and investigate provider concerns regarding claims payment, appeals, and resolution of operational issues. Coordinate with appropriate departments to research and resolve provider concerns
  • Respond to provider questions, phone calls, and inquiries in a timely fashion

Analyze Outpatient Cost Reporting for Providers
  • Assist in the analysis of monthly financial cost trends for the Texas Division
  • Analyze, prepare and review trend reports and detail by region for monthly presentations
  • Recommend solutions and assist in identifying action plans to remediate provider medical cost trends

Other Duties and Responsibilities
  • Participate in regularly scheduled meetings with other departments; offer substantive feedback to questions and research thoroughly any unknown issues
  • Available during working hours to coworkers and other partners for questions; including multitasking on calls as needed
  • Position will be temporary work from home until further notice
  • Other duties and responsibilities as assigned

While this job description is intended to be an accurate reflection of the duties involved in this position, the company reserves the right to add, remove or alter duties when business need dictates.

Job Qualifications

1-2 year's experience in a healthcare environment preferred

Bachelor's Degree preferred; High School Diploma required

Additional Skills: Excellent presentation, communication and customer service skills required. Excellent time management and relational skills. Demonstrated analytical skills. Strong organizational abilities with attention to detail.

Computer Skills: MS Office- Microsoft Word, Excel, PowerPoint

Travel up to 25%

This role is Flex which allows most work to be performed at home. Employees must be fully vaccinated if they choose to come onsite.

This position is not eligible to be performed in Colorado.

About Cigna

Cigna Corporation exists to improve lives. We are a global health service company dedicated to improving the health, well-being and peace of mind of those we serve. Together, with colleagues around the world, we aspire to transform health services, making them more affordable and accessible to millions. Through our unmatched expertise, bold action, fresh ideas and an unwavering commitment to patient-centered care, we are a force of health services innovation. When you work with us, or one of our subsidiaries, you'll enjoy meaningful career experiences that enrich people's lives. What difference will you make?

Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws.

If you require reasonable accommodation in completing the online application process, please email: SeeYourself@cigna.com for support. Do not email SeeYourself@cigna.com for an update on your application or to provide your resume as you will not receive a response.
Employer829 GulfQuest, LP