Provider Relations Representative I/II/III

company•City of Rochester, NY

1d•$24 - $47

About The Position

Summary: This position serves as the primary contact between Providers and the organization. The position is responsible for servicing assigned providers within a defined geographic market. Key responsibilities include educating and servicing physicians, dentists, hospitals and ancillary providers within established guidelines. This position works closely with all other internal departments including sales, medical, operations and network management. As a key representative of the corporation, this position is expected to maintain strong communication and build positive working relationships with local physicians, hospitals and ancillary providers. Essential Accountabilities: Level I · Recruit and retain all provider types to ensure network adequacy. · Facilitates provider education and training through documented face-to-face and virtual visits, educational forums, and orientations in order to increase Provider’s knowledge and satisfaction with the terms of their contract as well as Health Plan's benefits products, policies, programs, systems, new programs and products. · Provides orientation and training for all newly enrolled providers and their staff as well as annual training to the overall provider community. · Educates providers on care management programs, policies, and quality initiatives including but not limited to UM programs, case and disease management, HEDIS, risk adjustment and affordability programs in order to improve compliance, quality, efficiency, cost and program participation. ·Travel occasionally to community events and/or provider meetings outside of standard business hours to support relationship building and outreach efforts within the community. This flexible schedule, including some evenings or weekends, may be necessary to support the department. Travel is determined based on provider needs and may be required up to 25% of the time. This includes in-person visits to provider offices, meetings, training, and relationship-building activities as needed. · Coordinates with Medical policy and prior authorization teams to analyze and present data to providers in order to improve participation and/or compliance within established programs guidelines and enhance member health. · Builds physician, provider and facility relationships and satisfaction by conducting service visits both in response to provider requests and proactively on behalf of the organization. Plans, initiates, develops, coordinates, schedules and documents visits in conformance with department standards and geographic assignment. ·Encourages participation in annual physician and office manager satisfaction surveys. · Identifies and communicates trends that impact provider satisfaction. · Maintains awareness of competitive activity through relationships developed with providers and their office staff. On an ongoing basis, as part of monthly reporting, documents and shares information regarding market position including all competitive intelligence that would enable the organization to position ourselves favorably, as well as successfully respond to provider needs. · Provides expertise and assistance with guidelines relative to provider billing and payment, encouraging participation with programs and procedures designed to create operational efficiencies. Ensures that changes in billing procedures are communicated on a timely basis to all providers. Provides accurate feedback to internal departments to improve accuracy of system interfaces. · Serves as an internal expert and develops working relationships with internal departments in order to facilitate workflows and coordinate appropriate resources for problem resolution for providers. · Assists in the development of effective provider tools, educational materials and communications in conjunction with Provider Communications. Hosts provider educational events face to face. · Ensures that processes are being appropriately documented to support maintenance of the business. · Assists with training and mentoring of peer Provider Relations Representatives as needed to ensure departmental success. · Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and leading to the Lifetime Way values and beliefs. · Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures. · Regular and reliable attendance is expected and required. · Performs other functions as assigned by management. Level II (in addition to Level I Accountabilities) · Represents the Provider Relations department on Health Plan projects/initiatives. · Represents the Provider Relations department at Regional and Health Plan meetings as assigned by management. · Develops, coordinates, and leads provider educational activities. · Acts as the subject matter expert and point of contact for the department. · Provides leadership and guidance to junior Provider Relations Representatives. Level III (in addition to Level II Accountabilities) · Leads Health Plan projects/initiatives that have a direct impact on improving provider satisfaction. · Leads Provider Relations efforts to drive network and quality improvement. · Represents Provider Relations Management, as assigned, in governance structure forums and strategic projects. · Develops and nurtures positive relationships with strategic high-profile providers, including full health system, provider partners and ACQA providers.

Requirements

Bachelor’s degree in Business Administration, Health Care Administration or relevant field. Minimum of two year’s relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
In lieu of degree, individual must have experience that includes handling of escalated executive inquiries, training and/or presentations for staff or external customers.
Demonstrated experience with moderately complex projects that involve both written and verbal responses to physician or hospital inquiries.
Strong, persuasive and effective communication skills including previous experience with delivering communication to physicians and hospitals.
Experience in preparing and delivering oral presentations to individuals and small and large group audiences.
Understanding of medical care delivery and local market dynamics.
Familiarity with provider contracts and operational policies and procedures.
Understanding of products and services offered to Members.
Understanding of claim processing systems including provider file and claim workflows.
Knowledge of care management programs and their impact to Providers and Members.
Strong interpersonal skills with ability to interface effectively both externally and internally with a wide range of people including physicians, office staff and other health plan staff.
Excellent problem-solving skills with effective follow through.
Strong verbal and written communication skills; organizational and project management skills.
Minimum of 4 year’s relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
Demonstrated experience with complex and high-profile projects that involve both written and verbal responses to physician or hospital inquiries.
Working knowledge of provider contracts and operational policies and procedures.
Minimum of 6 year’s relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
Demonstrated experience with highly complex and high-profile projects that involve both written and verbal responses to physician or hospital inquiries.
Subject matter expert in care management programs and their impact to Providers and Members.
Ability to work while sitting and/or standing while at a workstation viewing a computer and using a keyboard, mouse and/or phone for three (3) or more hours at a time.
Ability to work in a home office for continuous periods of time for business continuity.
Ability to travel across the Health Plan service region for meetings and/or trainings as needed.
Must have a valid Class D license and ability to operate a motor vehicle.
The ability to hear, understand and speak clearly while using a phone, with or without a headset.

Responsibilities

Recruit and retain all provider types to ensure network adequacy.
Facilitates provider education and training through documented face-to-face and virtual visits, educational forums, and orientations in order to increase Provider’s knowledge and satisfaction with the terms of their contract as well as Health Plan's benefits products, policies, programs, systems, new programs and products.
Provides orientation and training for all newly enrolled providers and their staff as well as annual training to the overall provider community.
Educates providers on care management programs, policies, and quality initiatives including but not limited to UM programs, case and disease management, HEDIS, risk adjustment and affordability programs in order to improve compliance, quality, efficiency, cost and program participation.
Travel occasionally to community events and/or provider meetings outside of standard business hours to support relationship building and outreach efforts within the community.
Coordinates with Medical policy and prior authorization teams to analyze and present data to providers in order to improve participation and/or compliance within established programs guidelines and enhance member health.
Builds physician, provider and facility relationships and satisfaction by conducting service visits both in response to provider requests and proactively on behalf of the organization.
Encourages participation in annual physician and office manager satisfaction surveys.
Identifies and communicates trends that impact provider satisfaction.
Maintains awareness of competitive activity through relationships developed with providers and their office staff.
Provides expertise and assistance with guidelines relative to provider billing and payment, encouraging participation with programs and procedures designed to create operational efficiencies.
Serves as an internal expert and develops working relationships with internal departments in order to facilitate workflows and coordinate appropriate resources for problem resolution for providers.
Assists in the development of effective provider tools, educational materials and communications in conjunction with Provider Communications.
Ensures that processes are being appropriately documented to support maintenance of the business.
Assists with training and mentoring of peer Provider Relations Representatives as needed to ensure departmental success.
Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and leading to the Lifetime Way values and beliefs.
Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
Regular and reliable attendance is expected and required.
Performs other functions as assigned by management.
Represents the Provider Relations department on Health Plan projects/initiatives.
Represents the Provider Relations department at Regional and Health Plan meetings as assigned by management.
Develops, coordinates, and leads provider educational activities.
Acts as the subject matter expert and point of contact for the department.
Provides leadership and guidance to junior Provider Relations Representatives.
Leads Health Plan projects/initiatives that have a direct impact on improving provider satisfaction.
Leads Provider Relations efforts to drive network and quality improvement.
Represents Provider Relations Management, as assigned, in governance structure forums and strategic projects.
Develops and nurtures positive relationships with strategic high-profile providers, including full health system, provider partners and ACQA providers.