Provider Relations Representative, Experienced

Your Role

The Provider Services team provides knowledge and assistance to contracted entities in San Diego County. The Provider Relations Representative, Experienced will report to the Manager of Provider Services-Relations. In this role you will work closely with contracted providers to ensure that they are adhering to regulatory requirements. You will provide ongoing support of contracted entities, which includes working closely with internal teams to resolve any issues that may arise. Additionally, this role will support company initiatives, drive department objectives to achieve provider compliance, and focusing on building and maintaining strong relationships with contracted entities.

Your Work

In this role, you will:

• Implement strategies with providers to improve provider performance
• Coordinate escalated claim disputes and all necessary research timely and effectively
• 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
• Work closely with 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
• Develop and nurture positive relationships with contracted entities including individual practitioners, IPAs, and FQHCs
• Serve as the primary point of contact for providers addressing inquires, resolving issues and ensuring seamless communication
• Demonstrate resourcefulness and a proactive approach at resolving challenges related to the health plan such as provider relations and contracting
• Perform miscellaneous job-related duties as requested

Your Knowledge and Experience

• Requires a college degree or equivalent experience
• Requires 3 years of prior relevant experience
• Proven experience in provider relations, healthcare contracting or similar field
• Excellent communication skills, both written and verbal with the ability to articulate complex concepts concisely
• Highly organized with the capacity to manage multiple projects and prioritize effectively
• Demonstrated self-motivation, drive, and the ability to work autonomously while collaborating with the team
• Resourcefulness, adaptability, and quick learning abilities to thrive in a fast-paced healthcare environment