Provider Relations Specialist

Provider Relations Specialist - El Monte, CA

Employment Type: 1099/Independent Contractor

Compensation: $30 - $40 hourly

Nexus HR is looking for a Provider Relations Specialist to support provider network development and contracting efforts for an Independent Practice Association (IPA) in Los Angeles, CA. This 1099/Independent role focuses on building strong provider relationships, negotiating contracts, going over HEDIS measures, and maintaining an effective healthcare provider network. Job requires travel from Central CA (Kern, Bakersfield, Madera, Stanislaus Counties and Southern CA (LA, SB, Riverside). Company car is provided.

About the Job

The Provider Relations Specialist will develop and manage relationships with physicians, medical groups, health systems, FQHCs, RHCs, and ancillary providers. Responsibilities include provider contracting and negotiations, credentialing documentation, provider education, and resolving network-related issues. The ideal candidate has at least 3 years of healthcare provider contracting, HEDIS, Gaps in care experience, including experience with an IPA, medical group, clinics, payer, or insurance company. Fluent Spanish is highly preferred.

Duties and Responsibilities:

The Provider Relations Specialist supports the Network Development department by developing and managing provider relationships and contracting, gaps in care (HEDIS) efforts with providers, group practices, and ancillary providers based on network adequacy and client market needs.

• Provides service and education to Network Providers
• Liaise between the network providers and our organization, monitoring providers to ensure access standards are met
• Promote strategic initiatives and provide training for all lines of business to ensure that network providers have updated policy and procedure information
• Maintain documentation for all provider contracts via CRM
• Upload all documentation received by the provider, including but not limited to W-9, Rosters, and Credentialing applications, licensure, malpractice, etc.
• Contracts and renegotiates Primary Care, Specialty Physicians, and Ancillary Providers for all product lines
• Collects credentialing and required documents for newly contracted providers
• Conducts provider orientations and ongoing education to Network Providers
• Explains fee-for-service and risk contracts and provides reporting on Provider and/or Service Fund performance
• Manage provider network by developing and maintaining relationships to drive business results within a specific geographic area
• Interface daily with providers and internal constituents to effectively resolve service issues (contract inquiries, claim issues, authorization requests, eligibility verification) promptly
• Assist in developing/managing relationships with providers
• Negotiate cost-effective contracts in compliance with all state, provider, and client requirements
• Manage/negotiate contracts for non-contracted providers in established markets
• Research provider legal name, NPI, TIN, specialty, locations, phone numbers, website, etc; affiliating all parent/child relationships as appropriate
• Present HEDIS and GAPS in care reports to POC of clinics in IPA
• Computer literate to retrieve information from system for reports & presentation

Productivity Standards

• 20-40 provider contacts/day (Phone calls, emails, faxes)
• 5-10 Contracts/week; May vary depending upon project

Qualifications :

• 2 years of experience in healthcare provider contracting.
• 3 years of experience working with large health systems, FQHCs, RHCs.
• 3 years of experience working with large multi-specialty groups.
• Must have experience working for an IPA or a Medical Group.
• Must have experience in an insurance company or other payer building provider networks/contracting with physician practices, ancillary providers, facilities, or hospitals.
• Able to work in El Monte and travel as needed.
• Ability to speak fluent Spanish is highly preferred.