Provider Relations Representative, Experienced

Your Role

The Provider Service team is responsible for building and maintaining effective provider relationships with IPA/Medical groups, Providers and Hospitals. This entails services in the operational and compliance aspects of provider contracts and daily interaction with providers to effectively resolve service issues in a timely manner is a requirement. The Provider Relations Representative, Experienced will report to the Sr. Manager, Provider Services. In this role you will research and resolve provider inquiries, escalated issues, and operational challenges. Collaborate with cross-functional teams to support provider education, regulatory compliance, and process improvement initiatives. Exercise sound judgment in decision-making and seek guidance on highly complex issues when appropriate.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow - personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Knowledge and Experience

• Bachelor's degree or High School Diploma/GED and 4 years of additional relevant experience in lieu of a degree

• 3 years of prior relevant experience

• Strong analytical, critical thinking, and problem-solving skills with the ability to identify issues and develop effective solutions.

• Proficient in Microsoft Office applications, including Excel, Word, Access, and Outlook.

• Working knowledge of medical terminology and healthcare industry concepts.

• Experience working with Medi-Cal, Medicaid, or other government-sponsored healthcare programs preferred.

• Demonstrated ability to work independently, prioritize multiple assignments, and manage responsibilities with minimal supervision.

• Excellent organizational skills with strong attention to detail and accuracy.

Hybrid

This role requires employees to be in-office based on our hybrid workplace model, balancing purposeful in-person collaboration with flexibility. For most teams, this means coming into the office two days each week.

Employees living more than 50 miles from an office location will work with their manager to determine in-office time based on business need.

Your Work

In this role, you will:

• Implement strategies with providers to improve provider performance. Customize special education needs for providers as well as delivering strategic communications to assigned providers with good level of self-reliance.
• Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause.
• Implement or coordinate at least two geo-regional strategies with some support and guidance from manager.
• Coordinate data extracts and data analysis interpretation in preparation of reports aimed to determine necessity of rate increases to retain key PPO providers, with some support and guidance from peers or manager.
• Coordinate efforts to ensure BSC and its concentrated providers follow regulatory requirements.
• With some support from higher level PRCS, the Intermediate level is required to work closely with its assigned IPA/Medical Group to ensure it is compliant with Access and Availability requirements.
• Complete Transition and Disengagement Reports required by the Department of Manage Health care when IPAs/Medical Groups or Hospitals submit termination notices.
• Other duties as assigned.

Your Work

In this role, you will:

• Implement strategies with providers to improve provider performance. Customize special education needs for providers as well as delivering strategic communications to assigned providers with good level of self-reliance.
• Coordinate escalated claim disputes and all necessary research timely and effectively which may require some reliance on their manager and senior level peers in setting action plans to analyze and resolve root cause.
• Implement or coordinate at least two geo-regional strategies with some support and guidance from manager.
• Coordinate data extracts and data analysis interpretation in preparation of reports aimed to determine necessity of rate increases to retain key PPO providers, with some support and guidance from peers or manager.
• Coordinate efforts to ensure BSC and its concentrated providers follow regulatory requirements.
• With some support from higher level PRCS, the Intermediate level is required to work closely with its assigned IPA/Medical Group to ensure it is compliant with Access and Availability requirements.
• Complete Transition and Disengagement Reports required by the Department of Manage Health care when IPAs/Medical Groups or Hospitals submit termination notices.
• Other duties as assigned.