~4mo ago

HDSI: Provider Relations Manager

OtherManager

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Quick Summary

Overview

Job Objective / Purpose To provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation,

Technical Tools

OtherManager

Job Objective / Purpose

To provide end-to-end medical, operational, and strategic oversight across claims adjudication, provider management, accreditation, and internal medical support—serving as a critical bridge between Clinical, Customer Service, Finance, and Provider Networks.

Duties and Responsibilities

Lead provider engagement initiatives (planning, organizing, and execution)
Approve/deny reconciliation of accounts impacting provider payments
Perform in-patient adjudication, including proper segregation of illnesses
Review and approve facility accreditation and any changes
Handle and resolve Customer Service (CS) medical concerns and escalations
Review and evaluate contracts (providers)
Screen, accredit, and onboard CCM and clinic management doctors
Monitor PROs’ KRAs and overall performance
Initiate and support NetSuite PRT module upgrades (medical validation and process alignment)
Attend to medical needs of Flexicare employees
Provide real-time medical guidance to CSRs
Analyze utilization data and provide strategic recommendations to management
Diagnose and adjudicate claims to ensure accuracy and cost control
Ensure coordination across departments and business units for seamless operations