Provider Services - Provider Relations Representative 115-2006

JOB SUMMARY:

The Provider Relations Representative is the external-facing liaison between the health plan and its contracted providers. This role is responsible for onboarding new providers and delivering education on health plan policies, procedures, and clinical quality initiatives, including Star ratings, HEDIS measures, and care gap closures. The Representative will develop relationships with provider offices and ensure they have the tools and knowledge to optimize performance and compliance with health plan initiatives.

KEY RESPONSIBILITIES:

• Conducts initial provider onboarding sessions and ongoing educational sessions with contracted providers according to established standards. Provides ongoing education, develops agendas, organizes informational material, facilitates workshops and participates in meetings for assigned networks. Prepares regular correspondence and special mailings to assigned providers.
• Educates contracted providers on health plan policies, prior authorization process, claims procedures and escalation protocols
• Delivers focused training on quality improvement initiatives, including Star measures, HEDIS, care gaps and risk adjustment.
• Identify provider performance opportunities and collaborate with quality teams to support targets improvement plans.
• Serve as the primary contact for provider engagement on educational topics, ensuring a high level of customer service.
• Attend provider office visits to build rapport and provide on-site support.
• Track provider engagement and education activities and report on trends and performance metrics.
• Develop and distribute education materials and provider toolkits in collaboration with clinical, quality, pharmacy, and compliance teams.
• Communicate and coordinate with Provider Services Representatives.
• Works in tandem with the Provider Services Representatives to resolve member complaints and grievance issues.
• Participates in special projects and assignments as directed, including the development of new/improved operating procedures.
• Job may contain dimensions that could affect performance of responsibility, which may involve dealing with members who are sensitive and/or emotional.
• Perform other duties as assigned.

QUALIFICATIONS:

• Familiarity with Medicare Advantage, quality improvement programs, Stars ratings and HEDIS.
• Possess strong oral and written communication skills; experience conducting provider trainings.
• Ability to build positive relationships and provide consultative support to provider offices.
• Ability to monitor and assess rapidly changing information.
• Ability to think quickly and respond tactfully to sometimes difficult issues in dealing with providers.
• Successful completion of Health Care Sanctions background check.
• Proficient in Microsoft applications
• Willingness to travel local for routine provider visits.
• Must have a current driver's license and insurance verification and reliable transportation.

EDUCATION/EXPERIENCE:

• Bachelors degree in healthcare administration, public health or related field required OR each year of work experience in a healthcare or managed care setting can be substituted for each year of college not completed.
• Two to three years of industry related experience in managed care, insurance, physician environment or related area.
• Customer Service or sales-related experience preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin