For more information about this position contact:
Talent Acquisition Partner
The primary responsibilities of the Provider Relations Representative are to act as the liaison between THA & THPS and the PHCO (Physician Hospital Community Organization) provider offices and to manage the compliance requirements for THA & THPS. The Provider Relations Representative serves as the compliance officer for THA & THPS. The role includes maintenance of provider compliance for all contracted health plans, specifically pertaining to Fraud, Waste and Abuse and all other compliance training for providers. The Provider Relations Representative will collaborate with THA & THPS Plan COO/Director and other THA & THPS staff to establish/maintain departmental policies & procedures.
The Provider Relations Representative will be the primary point of contact for all office managers and other administrative personnel at THA & THPS member provider offices, as well as all ancillary and facility providers contracted with THA & THPS. This position will develop and maintain strategic relationships with Health Plans and Insurers in order to provide support to the PHCO provider offices by educating them about managed care contract requirements, helping them to maintain contract compliance, and advocating on their behalf with managed care organizations and other entities. Health Plan and Insurers include Health Share of Oregon, other Oregon Health Plans, Commercial and Medicare Advantage plans, as well as the Tuality Healthcare Employee plan and the Uncompensated Care Fund.
The Provider Relations Representative works directly with Health Share of Oregon (HSO) and other contracted health plans to manage all compliance related activities related to the HSO contract, including compliance with all HSO policies and procedures; Management and oversight of all audits required/requested by HSO; monitors regulatory landscape and provides appropriate and relevant training to THA & THPS staff to comply with regulations and to ensure that all audits, policies and procedures are properly adhered to by THA & THPS staff and providers; The Provider Relations Representative is responsible for managing the provider directory, provider data base and provider manual. The Provider Relations Representative is responsible for coordinating and hosting the quarterly provider offices meeting. The Provider Relations Representative works collaboratively with other THA & THPS staff, including Tuality Health Care, Risk Management Coordinator, Accounting and Claims.
a) Education: Bachelor’s Degree in Business, Healthcare Administration, or related field preferred. At least 3 years working in managed care, physician offices, compliance, hospitals or health insurance system.
b) License: ODL (Oregon Driver's License)
c) Demonstrates experience and knowledge of the Oregon Health Authority, Health Share of Oregon (HSO), as well as other regulatory agency standards.
d) General knowledge of provider reimbursement methodologies.
e) Knowledge of the Oregon Health Plan, local managed care market and providers.
f) Ability to work closely with THA & THPS’ Claims and Customer Service teams to address provider issues related to all aspects of claims and benefit interpretations.
g) Basic knowledge of professional and hospital contracting with health plans and insurers.
h) Ability to communicate effectively with key staff of health care provider and managed care organizations, as well as with business and industry leaders.
i) Excellent customer service skills.
j) Planning and organizational skills.
k) Ability to make large group presentations.
l) Proven problem solving skills.
m) Presents a good first and lasting impression by professional appearance and interpersonal skills.
n) Proven ability to communicate effectively and deliver training to all levels of internal and external customers.
o) Proven creativity, flexibility, and the ability to work under stress/multiple demands.
p) Self-directed and motivated to work with minimal supervision.
q) Experience working in highly confidential settings.
r) Uses PC software, including Microsoft Office, Cerner, MIDAS, Outlook, etc.
At Tuality Healthcare, an OHSU Partner, it's an honor and a privilege to serve those near us. That's why since our beginnings in 1918, and as we expand our strong network of services through our clinical affiliation with OHSU, we continue to be committed to providing the best health care possible and a valued community partner. Our affiliation with OHSU brings the advanced medical resources of Oregon’s only academic health center, which allows local providers to receive guidance from some of the country’s top specialists and pass that expertise on to Tuality patients where they can be cared for in their community.
Tuality’s many awards showcase our position as one of the Portland metro area’s premier healthcare providers, including 5th straight year in Top 10 Healthiest Employers in Oregon from The Portland Business Journal, Tuality’s 6th straight Gold Plus Award from the American Heart Association, and 2016 #1 Nationwide Best Hospital IT Department to work for according to Healthcare IT News.
Here at Tuality our employees care about making a difference. In fact, they care so much that in our most recent employee satisfaction survey we had an 80% participation rate! Tuality is truly unique because of the relationships we build and as individuals we are seen and heard. Come be part of our team, and let your voice be heard!