About the Department
Our Mosaic Clinically Integrated Network team is dedicated to fostering strong relationships between payors, clinics, and providers, ensuring seamless operations and compliance. We focus on provider enrollment, credentialing, and contractual adherence, all while supporting the broader mission of delivering exceptional healthcare to our communities.
Role Overview
As a Network Payor Relations & Compliance Specialist, you'll play a vital role in maintaining the integrity of our Clinically Integrated Network. You'll ensure providers meet regulatory standards, manage credentialing applications, and resolve claims issues. Your work will directly support providers, payors, and clinics, ensuring smooth operations and compliance with contractual obligations, ultimately contributing to high-quality patient care.
What You Will Do
- Ensure providers are enrolled in the Network according to current standards and regulations and maintains stringent compliance with payors.
- Facilitate preparation for the Network Credentialing Committee, reviewing files for accuracy and completion. Works with the Committee Chair to perform the administrative review process and attain approval sign-off.
- Serve as the point of contact for Network practices to address claims issues with Network payors by troubleshooting on behalf of the practice and working with the payor to resolve.
- Provide enrollment assistance/support to Network provider members as needed.
- Support new practice onboarding by providing support pertaining to credentialing, execution of participation agreements, health plan enrollment, fee schedules, and ensure smooth transition of support to Network practice transformation team.
- Perform data entry, collection, and analysis to complete tasks supporting provider primary source verifications and enrollment processes.
- Responsible for completing various audit activities to ensure contractual compliance and satisfying NCQA standards.
- Support Network patient alignment including but not limited to member transfer submissions and resolution tracking.
- Perform outreach to patients due for Medicaid redetermination, provides education to patients on process, answers questions, assists with online forms, and provides enrollment support.
- Follow procedures defined by Network’s patient compliant policy including reviewing patient concerns with Network administrative leadership and Network medical directors.
- Support the Network communications and education through creating a monthly payor newsletter capturing updates from Network contracted health plans including coding, billing, prior authorizations, upcoming webinars, operations, and provides CPT coding and billing education to Network members.
- Perform ongoing evaluation, maintenance, and execution of the Network participation agreements. Maintains all policies and procedures related to Network provider affairs and delegated credentialing.
EDUCATION/EXPERIENCE REQUIRED:
- High school diploma. Associate degree preferred.
- Two (2) years of provider enrollment, provider billing, or credentialing experience.
- Demonstrated knowledge of all aspects of the insurance provider enrollment process.
- Ability to work independently, in a demanding environment, managing deadlines and competing priorities without compromising quality or accuracy.
- Meticulous, highly organized with strong business acumen, quantitative and analytical skills.
- Excellent verbal and written communication skills.
- Comfortable and competent interpreting information and making decisions.
- Demonstrated ability to interact professionally with all levels of business and clinical organizations.
- Proficient in Microsoft suite of tools including Outlook, Word, and Excel.
- Proficiency in relevant applications including EPIC, Morrisey, and/or MDStaff preferred.
- Certified Professional Coder (CPC) preferred.
Why Henry Ford Health
At Henry Ford Health, we are relentless advocates for exceptional care for our patients, communities, and each other. We come to do meaningful work and grow our careers, and we stay for the connection, support, and shared pride in making the impossible, possible.