Provider Operations Representative

Position Summary:

Responsible for both the negotiation of provider contracts and ongoing education to the provider network in assigned market areas by performing the following duties.

Essential Duties and Responsibilities

• Engage in open face to face dialogue with physicians to communicate/educate important issues and updates.

• Ensure effective problem resolution facilitate communication between Prospect and Provider.

• Ensure all assigned providers are compliant with company-wide initiatives including Encounter Data, HCC and P4P programs, membership growth, MLR targets, etc.

• Ensure provider is well educated about the programs and implement specific workflows to meet initiatives and produce positive results.

• Track and report performance to measure results on a monthly basis and develop action plans for those non-compliant providers.

• Conduct Office Manager Meetings for assigned network physicians and develop plan to ensure high level of attendance.

• Identify and pursue standard, contracts with primary care physicians who have membership growth opportunities and lead successful execution and implementation plan.

• Identify management opportunities with IPAs and groups and directing leads to senior management for review and consideration.

• Actively work with network hospital(s) to identify and recruit new PCPs and high-volume hospital admitters.

• Maintain familiarity with all Medicaid and HMO Plan Network Requirements

• Maintenance of Pay for Performance and Risk Sharing Contracts

• Identify gains and losses and develop specific action plans to drive positive results for membership growth.

• Provides tactical operations support to assigned groups including contracting, data integrity, communications and relationship management.

• Prepares and delivers presentation with providers, provider staff, and/or physician leadership during monthly operational meetings.

• Understands, develops, tracks, monitors and reports on key program performance metrics, such as utilization, coding and quality.

• Performs root cause analyses and resolutions related to provider concerns, grievances, claims and care delivery.

• Researches issues that may impact future provider negotiations or jeopardize network retention.

• Documents site visits and results for NCQA purposes.

• Assists with ensuring that providers are compliant with NCQA requirements regarding availability and access to standards and evaluates the standards to ensure they address the requirements outlined by NCQA.

• Reviews claims reports for denials and works with providers to improve claim submissions and provider data updates to ensure accurate claim adjudication.

• Acknowledges any grievances and complaints within 1 business day of notice and resolves within 30 days.

• Educates providers regarding policies and procedures related to referrals and claim submissions, website usage, EDI solutions and related topics.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Skills and Abilities:

• Verbal and written communication skills.

• Ability to speak clearly and concise.

• Must be detail oriented and able to work independently in a fast-changing environment.

• Strong understanding of managed care and healthcare operations.

• Time management skills.

• Proficiency in analyzing, understanding, and communicating financial trends.

• Ability to manage multiple priorities in a fast-paced environment.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week.

*The company reserves the right to change the work schedules based on the company needs.

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic, travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating and preserving a culture of diversity, equity and inclusion.

Qualifications

• Must have Bachelor's degree.

• Previous HMO/IPA Operations experience preferred.

• 3-5 years of experience in the healthcare/insurance industry.

• Knowledge of Word and Excel.

• Must possess a valid Driver's License.