Provider Relations Representative

Special Note: Effective communication and de-escalation skills are required for this position. The incumbent must demonstrate the ability to establish and maintain positive working relationships with providers, navigate challenging conversations professionally, address concerns diplomatically, and resolve conflicts while fostering collaboration and trust.

PRIMARY PURPOSE

The Provider Relations Representative is responsible for providing exceptional business service to our network of participating providers by serving as the primary liaison between providers and the health plan as well as identifying new providers to complement and expand the network including Behavior Health and Physical Health. Continuously executes PCHP's network development plan to ensure best-in-class performance toward improving our quality of care, improving our patient experience, and reducing avoidable costs.

MINIMUM SPECIFICATIONS

Education

• High school diploma or equivalent required.
• Bachelor's degree in healthcare related field preferred.

Experience

• 5 years of provider support, education, negotiations, relationship management or contracting experience is required.
• 1 year of behavioral health experience required.
• 1 year of Texas Medicaid experience preferred.

Equivalent Education and/or Experience

• None.

Certification/Registration/Licensure

• Valid Texas Class C Driver's License required.

Required Tests for Placement

• None.

Skills or Special Abilities

• Excellent contract preparation skills, with an in-depth knowledge of provider reimbursement. Strong financial acumen with proficiency in analyzing and interpreting financial trends in the provider contracting arena.
• Advanced knowledge of network development strategies, clinical integration, and accountable value-based care principles.
• Proficient negotiation skills, including the ability to effectively engage providers, advocate for mutual agreements, and influence positive outcomes in complex situations.
• Expertise in gaining consensus and negotiating performance improvement plans.
• Excellent verbal and written communication skills including the ability to communicate effectively and professionally across disciplines. Ability to communicate complex information in understandable terms.
• Strong interpersonal and conflict resolution skills with the ability to establish and maintain effective working relationships across and beyond the organization. Such as assigned providers to include Hospitals, Rehabilitation/Residential Treatment Facilities, Local Mental Health Authorities, Substance Abuse Disorder Facilities, Federally Qualified Health Centers, Rural Health Centers, Ancillary, and other post-acute providers
• Excellent analytical and problem-solving skills.
• Strong time management and organizational skills with the ability to manage multiple demands and respond to rapidly changing priorities.
• Ability to write clearly and succinctly with a high level of attention to detail.
• Proficient computer and Microsoft Office skills. Ability to learn new software programs.
• Knowledge of Texas Medicaid, National Committee for Quality Assurance (NCQA), the Uniformed Managed Care Contract, Texas Department of Insurance, Office of the Inspector General, the Uniform Managed Care Manual, and other state agencies involving claims and Fraud, Waste and Abuse programs.
• Knowledge of Current Procedural Codes (CPT), ICD-10, CMS 1500 professional claims, UB ancillary, and hospital clean claim guidelines.

Responsibilities

Operations

• Performs research and resolution of claims processing workflow and quality improvement process and provider reimbursement issues.
• Uses analytic tools to track both health risks and compliance, as well as supporting the contract negotiation process.
• Executes provider recruitment to ensure network adequacy and resolves network access gaps.
• Executes on-boarding, education, and outreach activities to ensure provider adoption, adherence, and compliance with Parkland Community Health Plan (PCHP) quality management and accountable value-based care program.
• Performs provider on-boarding and orientation, including the development of related presentation materials,
• Conducts organized meetings with assigned providers and develops all supportive materials including meeting minutes, action plans, memoranda, etc.
• Supports and collaborates with all PCHP functional areas. Works on complex system-wide initiatives and acts as project lead.

Quality

• Integrate health literacy principles into all communication including Members and Providers.
• Support strategies that meet clinical, quality and network improvement goals.
• Promote the use of Health Information Technology to support and monitor the effectiveness of health and social interventions and make data-driven recommendations as needed.
• For staff in clinical roles, foster collaborative relationships with members and/or providers to promote and support evidence-based practices and care coordination.

Regulatory and Compliance

• Conducts continuous education and outreach to ensure adoption, adherence, and compliance with PCHP policies, procedures, quality improvement and value-based care programs.
• Ensures work is carried out in compliance with regulatory and/or accreditation standards as well as contractual requirements.

Professional Accountability

• Promotes and supports a culturally welcoming and inclusive work environment.
• Acts with the highest integrity and ethical standards while adhering to Parkland's Mission, Vision, and Values.
• Adheres to organizational policies, procedures, and guidelines.
• Completes assigned training, self-appraisal, and annual health requirements timely.
• Adheres to hybrid work schedule requirements.
• Attends required meetings and town halls.
• Recognizes and communicates ethical and legal concerns through the established channels of communication.
• Demonstrates accountability and responsibility by independently completing work, including projects and assignments on time, and providing timely responses to requests for information.
• Always maintains confidentiality.
• Performs other work as requested that is reasonably related to the employee's position, qualifications, and competencies.

Job Accountabilities

• Identifies ways to improve work processes and improve customer satisfaction. Makes recommendations to supervisor, implements, and monitors results as appropriate in support of the overall goals of PCHP.
• Stays abreast of the latest developments, advancements, and trends in the field by attending seminars/workshops, reading professional journals, actively participating in professional organizations, and/or maintaining certification or licensure. Integrates knowledge gained into current work practices.
• Maintains knowledge of applicable rules, regulations, policies, laws and guidelines that impact the area. Develops effective internal controls designed to promote adherence with applicable laws, accreditation agency requirements, and customer requirements. Seeks advice and guidance as needed to ensure proper understanding.