Health Plan Liaison

Company: Shriners Hospitals For Children ( Learn More )

General Information
High School
At least 3 year(s)
Not Specified
Job Description

As part of the Shriners Hospitals for Children (SHC) Department of Medical Affairs, the Health Plan Liaison is responsible for deployment of governmental and commercial health plan requirements which SHC sites participate with.  The Health Plan Liaison will provide education and tools to the physicians, advanced practice professionals, and hospital and corporate staff regarding payor-specific guidelines for medical necessity, utilization management, prior authorization, quality metrics, and other requirements. 

The Health Plan Liaison will exemplify the mission, vision, values and customer service philosophy of Shriners Hospitals for Children in job performance and in service to other persons outside of and throughout the organization.


  • Develops and implements education, and training materials to facilitate payor-specific guidelines are diffused into practice.

  • Monitors, interprets and deploys NCQA payor and provider quality standards.

  • Facilitates regular reporting to internal departments, hospitals and headquarters leadership as needed.

  • Works closely with hospital and executive leadership, and appropriate hospital staff to expedite provider enrollment turnaround time.

  • Establishes and maintains close working relationships with hospital credentialing coordinators, network management, provider, other hospital/headquarter departments, and payer contacts as appropriate.

  • Plans and manages projects, budget and resource allocation.

  • Coordinates with Network Management to deploy health plans

  • Validates provider enrollments with health plans and coordinates with plans to ensure provider status is published and deployed to mitigate denials for professional fees.

  • Provides education with Care Management team to Optimize Health plan resource utilization.

  • Job Requirements

    The qualified candidate will have experience in the following areas: 

    • Three years of direct experience with managed care, third party and government insurance provider enrollment required
    • NCQA auditing and/or accreditation experienced preferred
    • Medicare/Multi-state Medicaid experience preferred
    • Knowledge, development and implementation of enrollment workflow processes preferred
    • Demonstrated experience with change management and ability to influence people not in a direct reporting relationship preferred

    Minimum Education Required/Preferred:

    • Associates Degree or Business or Healthcare related field required
    • Bachelor’s Degree preferred

    Knowledge, Skills, and Competencies:

    • Demonstrate ability to exercise discretion and independent judgment, including using various resources and seeking input from appropriate personnel throughout the organization in decision-making process, to address issues, and provide guidance to hospitals
    • Coordinate inter-departmental efforts to improve processes in the organization
    • Ability to speak effectively before a group, conduct training sessions and conferences
    • Ability to adapt to flexible work schedules and frequent interruptions
    • Ability to problem solve, and effectively negotiate conflict
    • Knowledge of healthcare environment and healthcare delivery systems
    • Knowledge of medical provider credentialing procedures and standards
    • Data management skills including querying, reporting, and document generation
    • Maintains strict confidentiality with regard to provider information and understands/adheres to HIPAA Privacy & Security policies and procedures
    • Well-organized, detail oriented and able to meet deadlines with minimal errors

    • Strong written, phone, and verbal communication skills; proven ability to communicate with physicians and leadership

    • Must be able to lead and work cohesively in a team oriented environment and be able to foster good working relationships with others both within and outside the organization