Provider Network Representative at Troy Medicare – Pinehurst, North Carolina

Founded by independent pharmacists in 2018, Troy's founders set out to build a health plan option that is comprehensive and easy to understand for every single member.

Troy Medicare now serves thousands of Medicare-eligible low-income beneficiaries in the most underserved communities in the United States.

The Provider Network Representative (PNR) will be responsible for serving as the primary liaison between Troy Medicare and network participants (physicians, providers, and administrators) of the health plan provider network. Reporting directly to the leadership of Network Development with a matrix reporting to the leaders of Troy’s Health Plan Operations, this position will build and nurture positive relationships with health plan network participants by providing orientations, training, assisting with contracting activities and delivering high quality service through regular engagement by phone and through scheduled in-person visits to provider offices.

This position will also partner and coordinate closely with other departments and/or service partners on the credentialing and recredentialing process, will periodically assist the Claims staff with auditing and troubleshooting of provider data to ensure proper claims adjudication. Under minimal direction, works directly with the Plan’s provider community to educate, advocate and engage as valuable partners, ensuring knowledge of and compliance with required policies and procedures while achieving the highest level of customer service.

Troy Medicare started in Concord, North Carolina when our founders saw so many people increasingly unable to afford their prescriptions. Big health insurance companies had become more expensive and less transparent in their pricing and benefits. Our mission is to provide a comprehensive and easy to understand Medicare plan for every single member.

● Maintains positive relationships with providers by conducting over-the-phone and on-site service calls to health plan network participants on a regular basis with a focus to improve the level of accuracy in claims submissions, addressing identified trends/concerns.

● Obtain roster and other updates, provide education and resource access, while maintaining open communication.

● Conducts provider outreach by providing training and guidance to enable network providers to become more self-sufficient in confirming eligibility, claims submission, submitting roster and other updates and payment by use of available tools.

● Provides on-going service/problem solving assistance to providers as needed and ensures providers are updated on newly revised policies and procedures and tools; is responsible for researching, documenting, and resolving provider concerns/issues within department guidelines; follows-up on issues and concerns and escalates to leadership as necessary.

● Gathers and ensures accurate data entry of provider data from contracted entities into required systems, databases and/or forms; conducts continuous quality review to ensure maintenance of accurate data.

● Work with internal and external partners to obtain, store and provide mandatory data elements, updates, and any data improvements.

● Coordinates and supports the Network Development, Operations and Executive team on the recruitment and contracting activities for physicians, providers, facilities or other similar entities based on health plan marketing projections, targeted populations, and identified service gaps.

● Schedules, conducts, and documents training with each participating provider and office/support staff within established department guidelines. Must document training provided and respond to subsequent requests for follow-up training in a timely manner.

● Addresses, researches and escalates claims, billing, and appeal and/or dispute issues for providers in a timely manner. Works closely with the Claims, UM and A&G team to resolve issues.

● Educates provider staff on trends that may be impacting accurate claims processing.

● Contributes to the development, content, and maintenance of provider training manuals, provider orientations (group and individual), and other provider education resources.

● Reviews provider directories for accuracy and completeness prior to publication and distribution.

Regularly verifies provider contact information and service details for accuracy of provider directories and member access.

● Supports organization in provider audits and filings that happen throughout the year to include providing ad hoc provider data reports and participating in calls as appropriate.

● Produce and provide senior management with performance and adherence data, reports on trends and other similar deliverables.

● Partner with impacted business owners, entities and Compliance to remediate issues of noncompliance and track/report the status of corrective actions.

● Follow company policies, procedures, guidelines, as well as state and federal insurance regulations.

● Collaborate with staff, business owners and delegates on ways to improve adherence to business and regulatory requirements.

● Perform other duties as assigned.

● Associate's Degree or equivalent years experience with provider contract, network development and management, or project management experience in a managed healthcare setting.

● 3 - 5 years customer service, provider service, or claims experience in a managed care setting.

● Working familiarity with various managed healthcare provider compensation methodologies, primarily across Medicare lines of business, including but not limited to, fee-for service, capitation and various forms of risk, ASO, etc.

● Intermediate or advanced Excel skills for data analysis required.

● Strong understanding of insurance products, benefits, coverage limitations, laws and regulations as it applies to the health plan.

● Proficient in using MS Office products, Google Suite or other similar systems.

● Knowledge of systems and technology and proficient with data analytics.

● Problem solving and critical thinking skills, with the ability to conduct research and identify steps required to resolve issues and follow through to completion.

● Excellent communication skills-both written and verbal and active listening skills.

● Passionate about changing the healthcare experience for our members.

● Energized by helping people and seeing the positive impact of your efforts.

● Resourceful and enjoy solving complicated problems to get to the root cause.

● Self starter, flexible, adaptable, highly organized, and proactive.

● Strong relationship building skills.

● Ability to learn quickly and adapt to change.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the functions. Work involves exerting up to 20 pounds of force occasionally and/or a negligible amount of force constantly to move objects. The use of arm and/or leg controls requires exertion of force greater than that for Sedentary Work and the worker sits most of the time, the job is rated for light work.

The company is an Equal Opportunity Employer, drug free workplace, and complies with ADA

regulations as applicable.

This job description in no way states or implies that these are the only duties to be performed by the employee(s) incumbent in this position. Employees will be required to follow any other job-related instructions and to perform any other job-related duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities. To perform this job successfully, the incumbents will possess the skills, aptitudes, and abilities to perform each duty proficiently. Some requirements may exclude individuals who pose a direct threat or significant risk to the health or safety of themselves or others. The requirements listed in this document are the minimum levels of knowledge, skills, or abilities. This document does not create an employment contract, implied or otherwise, other than an “at-will” relationship.

Troy Medicare IS AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, national origin, age, genetic information, military or veteran status, sex, marital status, gender identity or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.