Provider Relations Representative - External

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.  This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

•    Integrity

•    Accountability

•    Collaboration

•    Trust 

•    Respect

Disclaimers:

•    Flexible work schedule is based on job duties, department, organization, or business need.

•    Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Provider Relations Representative-External is a field-based position is responsible for ensuring effective communication, compliance, and support for network providers, dedicating a minimum of 75% of time to provider visits, community engagements, and on-site activities. As the primary liaison between providers and the organization, the representative is tasked with resolving inquiries, facilitating onboarding processes, and delivering targeted education on policies, regulatory requirements, and reimbursement methodologies. Through proactive collaboration with internal departments, the representative ensures seamless coordination for claims resolution, contracting questions, and data management.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

•    Initiate and maintain effective channels of communication with GCHP network providers.

•    Provide the onboarding of new GCHP network providers to ensure full compliance with regulatory requirements.

•    Travel to provider offices at a minimum of 4 working days per week.

•    Build and nurture relationships with healthcare providers, community-based organizations, and other key stakeholders in the designated region to promote the health plan’s goals and ensure robust network participation.

•    Act as a primary external point of contact for provider inquiries, resolving issues promptly. Educate providers on health plan policies, procedures, and compliance requirements to enhance efficiency and service delivery.

•    Represent the health plan at local events, health fairs, and professional gatherings. Develop and deliver presentations to increase awareness and advocate for the organization’s services within the community.

•    Conduct regular provider visits to gather data, identify trends, and assess provider performance. Provide actionable insights and detailed reports to internal teams to support strategic decision-making.

•    Work closely with cross-functional teams, including internal provider relations teams, operations, and customer service, to align provider activities with GCHP goals and improve the overall provider experience.

•     When required, assist departmental operations with investigating contracting questions, including interpretation of contract language as it pertains to the roles and responsibilities of a GCHP network provider, coding and reimbursement methodology.

•    Manage and maintain GCHP network provider data and rosters to ensure additions and terminations of participating providers, address/demographic changes, name changes, TIN, NPI updates and provider practice information changes are timely and accurately submitted to all applicable operational systems.

•    Facilitate first call resolution, when appropriate, for GCHP provider questions and concerns.

•    Drive the resolution of escalated questions and concerns efficiently by actively engaging wi