Provider Resolution Director
Elevance Health

Provider Resolution Director (JR131497)

Location: Candidates must reside within 50 miles or 1-hour commute each way of the above Elevance Health PulsePoint location.

Elevance Health supports a hybrid workplace model (virtual and office) with PulsePoint sites used for collaboration, community, and connection, with the in-office commitment for this role being 1-2 days in an office per week.

The Provider Resolution Director is responsible for developing and maintaining positive provider relationships, dedicated to National Facility/ Ancillary provider groups with total annual spend up to $1B. May also be focused on multiple Facility contracts in one state or across a particular region of the state.

How will you make an impact:

• Conduct or collaborate on regular on-site and/or virtual/digital visits, communicates administrative and programmatic changes, and facilitates education and the resolution of provider issues.
  
• Serving as a knowledge and resource expert regarding the most complex National Facility/Ancillary provider issues impacting provider satisfaction, researches and resolves the most complex provider issues and appeals for prompt resolution.
  
• Where the individual is focused on one state or across a particular region of the state, that individual shall take on a "Senior" role in collaborating with existing resolution staff as well as with their assigned accounts.
  
• They will work with internal matrix partners to triage issues and submit work requests.
  
• Functions as a high level technical resource to resolve or facilitate complex provider issues, both internally and externally.
  
• Leads (or co-leads) Joint Operation Committees (JOC) of National Facility/ Ancillary provider groups or state-specific or regional accounts, driving the meetings in the discussion of issues and changes, specifically highlighting strategic opportunities.
  
• Provides assistance regarding Annual Satisfaction Surveys and required corrective action plan implementation and monitoring education, contract questions and non-routine claim issues.
  
• Coordinates (or collaborates in) communications process on such issues as administrative and medical policy, reimbursement and provider utilization patterns.
  
• Coordinates (or collaborates in) prompt claims resolution through direct contact with providers, claims, pricing and medical management department.
  
• Manages inventory impacting up $500M A/R, conducts claim and trend analysis.
  
• Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery.
  
• Researches issues that may impact future provider negotiations or jeopardize network retention.
  
• Shall provide mentorship, training, guidance to PRMs.
  

• Bachelor's degree and a minimum of 5 years of Provider service experience including 5 years' experience healthcare or provider environment; or any combination of education and experience, which would provide an equivalent background.
  

• Claims Experience including handling complex claims and ensuring claim payment accuracy is highly preferred.
  
• Provider Relations/Provider experience is highly preferred.
  
• Contracting and Credentialing experience is preferred.
  
• Understanding of Provider Data and Operations.
  
• Experience with high level provider escalations.
  
• Experience translating contract language into maintenance of data.
  
• Experience presenting to leadership / executives preferred.