Provider Relations Specialist

The Provider Relations Specialist for the continued development, implementation, compliance management of a cost-effective provider network, and support the day to day operational needs. This role will assist in the development of network-wide strategies to improve efficiencies and access. Under the direction of the Contract Manager, s/he performs all critical functions necessary to assess, develop, maintain, and/or improve provider network adequacy and performance.

In addition, you will be responsible for contributing to the growth and success of HealthTexas while upholding our Mission, Vision and Values.

Culture and Values Expectations

At HealthTexas, we believe that our workplace culture is the cornerstone of our success. We are committed to fostering an inclusive, collaborative, and innovative environment where every Associate feels valued, empowered and motivated to reach their full potential. Our culture is the driving force behind our mission "to deliver quality and compassionate care with outstanding service, every patient, every time". As a Provider Relations Specialist at HealthTexas we expect you to embody and promote our Values and defined behavioral expectations.

• Integrity: Do the right thing, the right way, every time.

• Be honest and uphold commitments and responsibilities, earn the trust and respect of the team and those we serve, and maintain privacy and confidentiality.

• Compassion: Treat everyone with respect and dignity.

• Foster an environment of inclusivity and well-being, practice patience and empathy, and assume positive intent.

• Synergy: Collaborate to improve outcomes.

• Invite and explore new opportunities, promote effective communication and teamwork, take pride in yourself, your work and HealthTexas.

• Stewardship: Use resources responsibly and efficiently.

• Implement effective strategies to attain goals, achieve maximum productivity and results, and seek continuous knowledge and improvement.

Essential Job Duties & Responsibilities

• Provides support to the Strategic Development and Managed Care department for both value based programs and FFS contracts

• Performs both internal and external outreach, monitoring, and resolution of operational and/or contractual provider related issues

• Educates provider's staff and providers on policies and managed care/medical group expectations

• Identifies network gaps and performs recruitment to address adequacy needs within the network

• Will help execute, maintain, and review Value Based, Capitation, and FFS contracts

• Be familiar with and have the ability to interpret policy and procedures to the relation of various healthcare contracts

• Coordinates the management of internal HealthTexas systems to ensure the accuracy of the provider network.

• Ability to manage and track projects and communicate the progress of the projects to senior leadership

• Participate in audits and readiness assessments for contract compliance

• Exhibits understanding and sets priorities to handle multiple tasks simultaneously, and designs work plans to track progress, resolve issues, and efficiently and effectively see tasks to completion

• Investigate and respond to complex provider related issues and initiate change of provider related database information

• Serve as a subject matter expert for provider relations activities

• Participate in audits and readiness assessments for delegation compliance

• Assists with In Network provider inquires and provider/group demographic changes within HealthTexas' claims and electronic medical record systems

Experience

• 2+ years of experience with provider service/provider relations operations/managed care, or relevant experience preferred

• Knowledge of Federal and State law, NCQA, Medicare, Medicaid, and relevant guidelines, regulations and standards; i.e., claims processing, UM programs, provider contract administration, , HEDIS, CMS STARS, etc.

• Effective communication (both verbal and written) and relationship building skills

• Team-player, innovative, problem solver,

• Possesses experience in and a working knowledge of managed care plans and programs

• Must be detail-oriented, well organized, have the ability to multi-task effectively, manage time and meet deadlines

• Expertise in Microsoft Office programs and industry-standard applications as appropriate

Education

• High school diploma or equivalent.

• Preferred Bachelor's degree in Business Administration, Health Care Administration or other related field

Knowledge, Skills & Abilities

• Demonstrates commitment to high professional ethical standards.

• Ability to adapt to a fast paced, continually changing business and work environment while managing multiple priorities.

• Knowledge of health care, managed care, Medicare and Medicaid.

• Strong technical, analytical, and trouble-shooting skills.

• Excellent follow-through skills; self-motivated and detail-oriented.

• Strong organizational skills to manage multiple projects, issues, and priorities effectively and simultaneously, with attention to detail.

• Highly analytical and detail oriented with strong interpersonal written and oral communication skills.

• Expertise in Microsoft Office programs and industry-standard financial applications as appropriate

Work Hours, Travel Requirements

• Monday

• Friday, 8:00 a.m.

• 5:00 p.m., and as needed to complete projects.

• Travel to medical offices may be necessary for the purpose of providing benefit education.

Working Conditions & Physical Requirements

• This job operates in an office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, scanners, filing cabinets and fax machines.

• 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. While performing the duties of this job, the employee is regularly required to talk and hear. This is largely a sedentary role; however, some filing is required. This would require the ability to lift files, open filing cabinets and bend or stand on a stool as necessary. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

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