Provider Relations Representative

PROVIDER REALTIONS REPRESENTATIVE

Overview

To establish and maintain excellent relationships with the provider network in a specific geographic region, including healthcare practitioners, office staff, and administrators. Works closely to identify and resolve complex issues, provides education and staff training. Provides service and education via onsite visits and telephone. Assists providers with understanding managed care of California's policies and procedures and assists with resolving issues that arise.

Responsibilities :

• Investigates and responds to provider concerns. Serves as a liaison between providers and SPN,IPA departments in responding to questions and resolving issues. Assists with research and disposition of provider appeals and grievances.
• Identifies network gaps and performs recruitment to address community network needs.
• Build and maintains relationships with all network providers.
• Trains provider / ancillary offices via onsite visits and by telephone regarding SPN IPA policies, procedures, and available resources, referral, claim processing, portal access.
• Creates educational materials and formal presentations.
• Conducts and maintains office site visits to service providers with training and education, resolves issues, educates and interprets staff / providers on policies and procedures, collects credentialing information and reviews Healthcare Effectiveness Data and Information Set (HEDIS) information.
• Educates providers on the use of IPA provider information forms. Follows up with providers on incomplete forms to obtain required information.
• Resolves complex authorization or claims issues. Identify potential system issues, collaborate with affected departments to ensure resolution.
• Conducts, quarterly utilization management meeting, annual and ad hoc, and provider / member surveys. Coordinates, attends, and participates in various meetings both on and off-site as assigned.
• Creates Corrective Action Plans (CAPS) for provider sites that did not meet standards. Monitors compliance with CAP.
• Uses databases and tracking systems to document and retrieve information and run reports.
• May be required to report on major points, resolved and pending action items.
• Required to work with minimal supervision.
• Other duties as assigned.

Qualifications :

Education and Experience :

Requirement :

Work Environment And Physical Demands :

Hours : Mon – Friday 40 hrs. a week

Paid : Holidays, Vacation and Sick Days

At least 50% of work time is spent driving and more than 30% of work time is spent in office. Ability to lift, carry or move objects of varying size, weighing up to 15 lbs.

Compensation between $25 and $30 / hr x 40 hours a week.

Medical, Dental and Vision insurance available after 90 days.  401K after 6 months.