Provider Relations Representative - PCP

Become a part of our caring community The Provider Relations Representative is responsible for day‑to‑day, front‑line relationship management for network providers in Humana Healthy Horizons in Virginia Medicaid Plan. This role supports provider onboarding, training, education, and inquiry/issue support and resolution. The individual in this role should have critical thinking/problem solving skills, an understanding of health plan operations, and strong interpersonal skills. This role develops and grows positive, long‑term relationships with physicians, providers and healthcare systems. Responsibilities Serve as primary relationship manager with assigned providers to ensure positive provider experience with Humana Healthy Horizons and promote network retention Meet regularly, both in‑person and virtually, with assigned providers to conduct training and education, including, but not limited to, required annual trainings, periodic updates to and/or reviews of Humana policies and procedures, and Humana systems training and updates Support newly assigned providers with onboarding, including hosting orientation session(s) Respond to assigned provider inquiries and support prompt issue resolution, including, where necessary, collaboration with appropriate enterprise business teams (ex., claims payment, prior authorizations & referrals) Work with internal resources and systems (e.g., claims, reimbursement, provider enrollment) to provide the Exceptional Experience in all provider interactions Create provider trainings based on provider feedback, trends in claims or process changes Educate provider on location and content of all provider facing materials (Orientation, Provider Manual, Newsletter, Program Updates, Etc.) Convene regular meetings with providers, including organizing agendas, materials, meeting minutes, other team members (clinical, provider engagement), to discuss key operational, clinical, and quality related topics Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, Availity, Quality resources, and member resources Communicate updates on Humana's policies and procedures and Cardinal Care programmatic updates Coordinate periodic regional provider townhalls and/or trainings Attend Network Meetings/Conferences Job Details Location: Remote (Virginia), with up to 25% travel to Humana Healthy Horizons office in Glen Allen, VA Time Commitment: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST) Required Qualifications Must reside in the Tidewater Region of Virginia 2+ years of health care or managed care experience working with providers (e.g., provider relations, claims education) Experience working with physical health providers, facilities, ancillary providers, and/or FQHCs Experience in provider operations, building strong relationships with provider organizations, financial/contracting arrangements, and/or regulatory requirements Exceptional relationship management and interpersonal skills Proficiency in analyzing, understanding, resolving, and communicating complex issues Exceptional time management and ability to manage multiple priorities in a fast‑paced environment Thorough understanding of managed care contracts, including contract language and reimbursement Exceptional written and verbal communication skills Strong presentation and facilitation skills Knowledge of Microsoft Office applications Field based in Virginia and requires frequent travels to provider and Humana locations Preferred Qualifications Experience with Virginia Medicaid Understanding of claims systems, adjudication, submission processes, coding, and/or dispute resolution Understanding of service coordination, prior authorizations, and other health plan processes Understanding of value‑based payment programs Equal Opportunity Employer It is the policy of Humana not to discriminate against any employee or applicant for employment because of race, color, religion, sex, sexual orientation, gender identity, national origin, age, marital status, genetic information, disability or protected veteran status. It is also the policy of Humana to take affirmative action, in compliance with Section 503 of the Rehabilitation Act and VEVRAA, to employ and to advance in employment individuals with disability or protected veteran status, and to base all employment decisions only on valid job requirements. This policy shall apply to all employment actions, including but not limited to recruitment, hiring, upgrading, promotion, transfer, demotion, layoff, recall, termination, rates of pay or other forms of compensation and selection for training, including apprenticeship, at all levels of employment. #J-18808-Ljbffr Humana