Provider Relations Representative 3

Overview

The Provider Relations Representation is responsible for establishing and maintaining effective relationships with network and affiliated practitioners, provider groups, hospital and facility organizations to ensure access to care for Kaiser Permanente members. The Representative will partner with provider contracting, care delivery and network operations to develop and expand the provider network to meet geographic and service line objectives. This position delivers orientations, training and high-quality service through regular provider engagement via phone, video or in-person visits, as well as addressing provider inquiries, reimbursement disputes, and resolving complex inquires relating to billing, pricing, policy, systems, and benefits.  

Join our medical group

Northwest Permanente is a self-governed, physician-led, multi-specialty group of 1,500 physicians, surgeons, and clinicians, caring for 630,000 members in Oregon and Southwest Washington. Kaiser Permanente is one of the nation's preeminent health care systems, a benchmark for comprehensive, integrated, value-based, and high-quality care.

Responsibilities

Major Responsibilities / Essential Functions

Network & Policy Insights

• Identifies provider trends, conducts market intelligence to understand key issues and reports to leadership
• Assist in clarifying state laws and Medicare/CMS and NCQA regulations/requirements regarding managed care as required
• Remain current and well-versed in organizational and departmental policies and procedures, and developments in products and benefits which impact contracted providers
• Maintain knowledge of policies and procedures relating to utilization management, referral process, and claim adjudication

Provider Education & Outreach

• Schedule and perform initial orientation training to newly contracted network and affiliate providers, facilities, and individual practitioners
• Develop and maintain updates to training materials for use in large group or one-on-one settings
• Provide routine guidance to network providers and staff to become more self-sufficient in confirming eligibility, claims submission and payment by use of available tools
• Participate in the coordination of timely communication to introduce new products, insurance policy and procedure changes and updates on referral and utilization management protocols
• Develop content, edit and publish information in the Provider Manual and portals

Relationship Management

• Build, support, and maintain critical relationships with network and affiliated practitioners, provider groups, hospital and facility organizations to ensure practitioner satisfaction and effective participation with all KP lines of business
• Facilitate partner meetings; Develop pertinent documentation for a service call in response to a specific provider request or routine office visit
• Conduct satisfaction surveys, assess results; develop and implement improvement plans

Issue Resolution

• Research, resolve and respond to provider inquiries and complaints from contracted network and affiliate providers related to billing, pricing, policy, systems, benefits, and reimbursement
• Identify, analyze and document root cause for issue and facilitate changes through key departments to prevent further incidences

Project Delivery

• Work cooperatively with Network Operations Managers, cross-functional operational, insurance and physician teams to customer needs and improve processes

Department Operations

• Manage the day-to-day department operations, assuring quality customer service and support for clients and staff
• Develop a framework and associated templates for provider orientations, issue resolution and customer service requests/tracking
• Prepare reports and dashboards for leadership
• Mentor department staff to achieve optimal performance
• Assume responsibilities for Management in his/her absence

Qualifications

Minimum Education

• Bachelor's degree in healthcare, business or related discipline

Minimum Work Experience

• Minimum five (5) years of healthcare experience focused in provider relations, contract design/negotiation, claims processing, education/training or clinician facing customer service
• Minimum two (2) years in Provider Relations
• Minimum three (3) years progressive supervisory experience including allocating work assignments, conducting performance reviews, and providing performance coaching

Additional Requirements

• Excellent interpersonal and customer service skills required
• Ability to develop and maintain positive working relationships with both internal and external stakeholders
• Ability to work cooperatively, sensitively and tactfully while maintaining professionalism with all levels of staff and the general public required
• Understanding of health insurance claims, as well as an ability to analyze data to resolve provider service issues
• In-depth knowledge of healthcare issues and a variety of physician office procedures, concepts and practices
• Experience in leading and managing projects in a matrix environment
• Ability to operate in politically sensitive environment and navigate situations while maintaining positive relationships
• Strong presentation and training skills required in group settings
• Work with minimal guidance and escalate issues as appropriate
• Proficient with Microsoft suite of applications: Word, Excel, Desktop Publishing, Visio and Outlook
• Ability to deal with emotionally charged and difficult personalities with regards to claims payment and contractual issues
• Ability to travel to partner sites (at least 50%)

Required Licensure, Certification, Registration (LCR)

• Six Sigma or Lean Six Sigma Green Belt Certified within one (1) year in the role

Preferred Education

• Bachelors degree in healthcare, business, or insurance

Preferred Work Experience and Qualifications

• Minimum five (5) years of experience in provider relations
• Minimum two (2) years of experience in contract negotiation or design
• Experience in developing comprehensive training curriculum for internal staff and contracted providers
• Exceptional influencing and partnering skills at all organizational levels
• Ability to effect collaborative alliances, promote and foster teamwork
• Strong understanding of relational databases with desire to increase technical knowledge
• Ability to be resourceful, work independently, and manage time effectively
• Ability to delegate and handle multiple priorities
• Familiarity with CMS 5 Star, HEDIS, Risk Adjustment, and other Pay for Performance Programs desirable

Equal opportunity employer

At Northwest Permanente, we are committed to providing an environment of mutual respect where equal employment opportunities are available to all applicants without regard to race, color, religion, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical and mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military and veteran status, and any other characteristic protected by applicable law. Northwest Permanente believes that equity, inclusion, and diversity among our employees are critical to our success, and we seek to recruit, develop, and retain the most talented people from a diverse candidate pool.