Provider Relations Representative

Job Summary

The primary responsibility of this position is leading, engaging, and facilitating the development of CenCal Health's provider network through recruitment, contracting, communication, and developing relationships to support strategic organizational objectives. This position is responsible for advocating, appealing, recruiting, contracting, educating, maintaining, and improving provider participation and satisfaction.

The Provider Relations Representative is responsible for researching, analyzing, and coordinating the resolution of complex provider concerns, including assisting with the resolution of provider issues and grievances. The position is responsible for ensuring and assessing provider educational needs through the planning and conducting of training and workshops. The Provider Services Representative is also tasked with improving of provider participation and satisfaction.

This position requires presence within the community they are serving and assists providers via phone, email, and in-person visits.

The position reports to the Provider Relations Manager. Primary internal contacts include all departments within CenCal Health. Primary external contacts include all healthcare providers, their office staff, local public agencies, community organizations, and hospitals and healthcare facilities.

Duties and Responsibilities

• Serves as the primary department contact for all assigned contracted provider partners.

• Assists with the Provider Services Phone Queue ensuring customer service metrics are met.

• Responsible for maintaining the provider network within their assigned territory including provider recruitment, contracting and retention efforts, conducting on and off-site visits, providing orientation, ongoing education and training to providers and staff, and access to the Provider Network for all new and existing programs.

• Understands contractual terms and ensures provider awareness of such terms, including raising any potential instances of non-compliance.

• Maintains ongoing awareness of changes within their territory for the purpose of ensuring that provider data is accurate and up to date.

• Executes provider recruitment conducting outreach for needed provider specialty types.

• Participates in the review of CenCal Health's provider network and evaluation of member accessibility.

• Conducts provider visits to the contracted provider partners to improve engagement and provider satisfaction.

• Stays up to date with changes in CenCal Health policies, practices, and resources to effectively communicate applicable changes to each provider type.

• Acts as a provider liaison with Medical Management, Population Health, Claims, and Quality Improvement. Networks with other departments to ensure providers are supported.

• Composes provider notifications.

• Advocates on behalf of the providers to investigate provider issues, track resolution progress, prepare recommendations for resolution, compose responses, and document all communication.

• Coordinates and offers support to provider partners to improve performance in care-based incentives;

• Assists with the disposition of provider grievances.

• Generates reports to analyze provider billing concerns both proactively and retrospectively and works interdepartmentally to resolve issues

• Initiates administrative authorizations to address providers rendering services without authorization and follow up to ensure implementation of approved corrective actions.

• Assists with the maintenance of the department's provider database and data integrity.

• Participates in the development of Provider Bulletin articles, and provider manual changes.

• Educates providers by assisting with the development and distribution of education, promotional, and presentation materials.

• Develops and participates in provider training and workshops, as well as evaluates the effectiveness of training.

• Assists with special projects, including compliance with regulatory responsibilities; makes recommendations for improvement of any and all procedures and systems at CenCal Health.

• Represents the Provider Relations Department on internal CenCal Health project teams.

• Possesses in-depth knowledge of the restricted CenCal Health Provider Portal. Engages in training and encourages providers to utilize reports and functionality located within the portal. Provides portal demonstrations and assists in troubleshooting portal issues.

• Ensures contract compliance and high-quality standards by assisting providers in all phases of the contract process.

• Other duties as assigned by the Provider Relations Manager or Provider Relations Director.

Qualifications

Knowledge/Skills/Abilities

Required

• Knowledge of Medi-Cal benefits and managed care regulations

• Exceptional sales and marketing skills

• Excellent oral and written communication skills

• Exceptional computer software skills

• Strong analytical and research skills

• Excellent interpersonal skills

• Knowledge of the provider and members in each community is desired

• Ability to communicate professionally by phone, in writing and in person with colleagues, providers, and other health care professionals.

• Demonstrated strong multi-tasking, organizational and time management skills

• Ability to work with a high degree of independence while seeking guidance when necessary and escalating issues to supervisor timely

• Ability to handle multiple projects simultaneously and reset priorities daily.

Education and Experience

• Bachelor's degree in business, Public Health, or related field, or 4 years of health plan, healthcare, or public health experience

• At least 2 year's experience working with Medi-Cal/Medicaid/Medicare population or public health department.

• Desired prior experience in a managed care setting