Provider Relations Representative

Responsibilities:
Essential Functions:·Identification of potential providers within the network needs and requirements
·Negotiates contracts with identified providers·Monitors provider compliance with contract, including access, quality, and member satisfaction; monitors encounter submission data for trends and problems; coordinates issue resolution as needed
·Acts as content specialist in the developing network (behavioral health and Medicaid)
·Monitors provider’s availability and accessibility, including back-up coverage, hospital staff, and privileges of physicians
·Reports monthly and as required: member complaints about providers, noncompliance with administrative and medical protocol, medical claims review report and others as required
·Monitors, reports, and communicates to Quality Management quality issues
·Prepares data analysis and monthly reports as assigned regarding provider network and provider network needs
·Evaluate membership and member/provider ratios,·Performs onsite office reviews;·Monitors accuracy and timeliness of provider information/modification data entry in provider files of QMACS system
·Initiates contract negotiations, contract approval process; within plan medical management, operational and financial goals; ensures 100% accuracy of information, appropriate signatures, and data entry·Resolves provider issues regarding prior authorization, claims and other issues as they arise in a timely, efficient manner
·Trains providers and office personnel regarding plan processes, policies, and covered services; supplies follow-up training to ensure policy compliance and education continuity;·Disseminates written correspondence as necessary to address issues, problems, and new information
·Coordinates physician mailing projects
·Responsible for network development progress reportingSecondary Functions:·Works in a manner that is not disruptive to peers, supervisors and/or subordinates.
·Maintains regular and acceptable attendance at such level as is determined in the employer’s sole discretion.
·Must be available and willing to work such days and hours as the employer determines are necessary or desirable to meet its business needs.
·Must be available and willing to travel to such locations and with such frequency as the employer determines is necessary or desirable to meet its business needs.·Maintain professionalism, including phone etiquette, manners, appearance, and attitude
·Maintain effective working relationships with various providers, networks, and managed health care components
·Continue education regarding changes and trends in health care management and specific provider communities
·Other duties as assigned
REQUIREMENTS
Knowledge and Skills:
·Knowledge of contract negotiation and provider services.
·Sales and/or Marketing background a plust.
·Ability to speak and understand Spanish is preferred.
·Excellent interpersonal skills.
·Strong problem-solving skills.
·Ability to read, comprehend, and negotiate contracts and services at an intermediate level.
·Ability to write correspondence, procedures and policies, and supporting documentation.
·Ability to present information effectively in one-on-one and small group settings to providers and employees.
·Ability to use reason to define problems, collect data, establish fact, draw valid conclusions, and design, implement, and manage appropriate action plans.
·Ability to multi-task and organize and coordinate priorities.
·Ability to be a positive team player able to manage project time constraints and work with little supervision.·Ability to successfully utilize business application software, Microsoft Office suite and common computer and office hardware.
Education and Work Experience:
·Bachelor’s degree in business, health, management systems or related discipline preferred with a minimum of three (3) years experience with provider relations.
·Experience with physician providers, medical terminology, common coding, and billing requirements is required.·Demonstrated experience with claims processing and research required; advanced interpersonal skills, maturity, and good judgment is required. Working experience with QMACS is helpful.
·Must possess reliable transportation with proper insurance coverage, and be available for extensive travel both in and out of state.
·This position requires work experience in a complex, competitive environment with diverse racial and socio-economic factors.