Provider Relations Representative

Position Purpose: Exercise the duties and responsibilities delegated to the Provider Relations Representative with the outmost professionalism and dedication.

Responsibilities:

• Responsible for conducting provider orientations of newly contracted providers within the specified time frames as indicated in Policy & Procedure PR – 01.

• Responsible for securing a signed Notice of Educational In - Service Acknowledgement Form upon completion of each and every provider orientation session conducted.

• Responsible for maintaining original completed copies of the Notice of Educational In – Service Acknowledgement Forms in the form and format adopted from time to time by the VP of Provider Relations.

• Responsible for the dissemination of the Provider Handbook / Manual, Provider Bulletins, and applicable Policies and Procedures affecting the Health Plan’s Participating Network of Providers on a “as needed” basis.

• Responsible for conducting the Annual Site Visit for PCPs and High-Volume Specialists within the established time frames as indicated on Policy & Procedure PR – 02.

• Oversight of the participating provider accounts assigned to him/her by the VP of Provider Relations or her assigned designee

• Adhere to the delineated Periodic Site Frequency Parameters as may be applicable to established PCPs and High-Volume Specialists

• Complete the PCP Provider Site Visit Tool to the extent required for each and every Annual and Periodic PCP site visit conducted within their assigned service area

• Complete the Specialty Provider Site Visit Tool to the extent required for each and every Annual and Periodic Specialty site visit conducted within their assigned service area

• Conduct Provider After Hours surveys and periodically monitor the accessibility to access to care to ensure that it meets or exceeds such standards as may be established by CMS. 

• Responsible for all communication and training materials distributed to participating providers is up to date.

• Provide assistance in coordinating the Annual Medicare Advantage Health Plan Benefit presentation dinner meetings to Primary Care Physicians and others as needed.

• Active participate in Quality Management Program initiatives and QI special projects as may apply.

• Actively participate in the implementation of special projects logistics reporting pertinent to Provider Corrective Action Plans, Provider Surveys, Provider claim dispute settlements, etc.

• Effectively address all matters of Provider complaints and disputes as may be presented for resolution to the VP of Provider Relations.

• Maintain accepted and expected level of proficiency in Federal and State regulatory subject matters as mandated through CMS, AHCA and other applicable agencies governing the operations of Medicare Advantage Plans.

Qualifications:

• 3 - 5 years’ experience with a Medicare Advantage Health Plan or BS/BA Degree

• Commitment to the Health Plan’s vision and mission

• Excellent communication skills, both in oral and written

• Fully Bilingual English / Spanish (preferred)

• Demonstrable knowledge of provider reimbursement methodologies applicable to Medicare Advantage Health Plans and other federal health insurance programs

• Knowledge of CMS, AHCA and other federal and state current regulatory governing guidelines applicable to HMOs

• Excellent organizational skills

• Flexible Disposition to enable management of special projects

• Excellent Customer Service Skills to enable resolution of complex and varied situations involving multiple internal and external stake holders

• Ability to drive key organizational / operational initiatives

Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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