Provider Relations Representative jobs in the United States

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Job Summary

The Provider Relations Representative, develops and maintains service relationships with all participants (physicians, providers and administrators) of a provider network. Responds to electronic and direct inquiries from clients about policies, rates, changes, referrals, eligibility, credentialing, etc.

Essential Duties & Responsibilities

• Establish working relationships and collaborate with providers’ office staff in executing contracts and adhering to benchmarks set forth in all value-based programs

• Work with providers and office staff to ensure compliance with PPG’s requirements and expectations

• Perform site visits to conduct outreach, education, training and orientation sessions for providers and key administrative staff

• Identify value-based provider offices and vendors to be contracted by health plan.

• Monitor practice performance to ensure compliance with all contractual agreements, identify any barriers and make recommendations for corrective action plans and other interventions as required

• Review departmental and personal goals on an on-going basis with VP/ Director of Provider Relations

• Follow all applicable federal/state regulations with respect to Confidentiality and HIPAA, among others

• Mandatory attendance at quarterly membership meeting, monthly orientation seminars and monthly physician networking events which occur outside of regular business hours

• Interact in a professional, respectful and helpful manner

• Generate call and visit reports daily and document all practice encounters

• Conduct orientations/re-orientations

• Monitor of encounter data and act upon issues

• Update provider offices on policies & procedures

• Maintain network matrices & directories, including QNXT Provider database

• Adjustments, deductions, verification and distribution of Capitation checks/referral forms, including preparation of newsletter

• Identify “trends” in physician activity rather than react to occurrences

• Prepare and mail new physician contracts and follow-up upon approval from Membership Committee

• Credentialing as required by the client. Collect and present new physician applications to Membership Committee

• Negotiate one-time rate for out-of-network providers and prepare documentation

• Perform weekly review of QNXT Explanation of Benefits reports to ensure proper adjudication utilizing Medicare rules and IPA contract terms.

• Provide yearly update of provider manual

Additional Duties & Responsibilities

• Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice

Education & Experience

• Bachelor's degree required, masters preferred (MHA or MBA), or equivalent years of experience or Health Care Administration and/or Managed Care Organization or related field.

• 8-10 years related experience and/or training or experience/education

• Formal training in Medical Management/Utilization Management a plus

• Managed care experience (2 years) or 4 years work experience in a provider office environment

• Knowledge of healthcare industry – Health Plan, MSO, CMS, Federal regulations and downstream Medicare Advantage risk arrangements

• Excellent written/oral skills-Possess interpersonal/listening skills to interact effectively with individuals of all backgrounds, experience and educational levels

• Strong quantitative organizational and administrative skills

• Ability to manipulate large databases and to produce meaningful analytical and management reports

• Excellent Microsoft Office skills, including working knowledge of Excel and Word

Education Requirements

Required/Preferred

Education Level

Discipline

Required

Undergraduate Degree

Knowledge, Skills & Proficiencies

• Ability to perform complex problem solving

• Ability to work effectively with physicians

• Knowledge of HMO and MCO operations, and continuous quality and utilization/medical management techniques and operations

• Must have demonstrated knowledge of CPT, ICD-10, Medicare rules, RBRVS, & HCPCS coding

• Strong people and project management skills

• Demonstrated ability to develop and implement new business units and service lines

• Knowledge of Disease Management implementation models

• Comfort in Computer applications

• Knowledge of standardized HMO and Medicare Advantage benefit structures

• Project Management skills and experience are preferred

• Limited knowledge of medical terminology is preferred

• Fluent in English and Spanish

Physical Requirements

This position works under usual office conditions. The employee is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include the ability to lift up to 50 lbs.

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Conditions

Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing

Travel Requirements

Amount of Expected Travel

Details

Yes

0-25%

Job requires daily reliable transportation as work will involve some driving/traveling to assigned clinics.

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Disclaimer

The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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