Senior Provider Relations Advocate - Miami, FL - Bilingual Spanish Required

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Position Overview

The C&S Long Term Care Division requires this position for servicing the LTC provider network, to include provider contracting, credentialing and re-credentialing, conducting provider relations tasks, providing education, working in the provider portal and EVV (electronic visit verification), providing assistance with claims, ensuring network adequacy and closing gaps where necessary, along with network tracking and reporting. This associate works with the case management staff to assist with network needs for member benefits and services, to include working SCAs and PNRs (Single Case Agreements and Provider Network Requests).

The Sr Provider Relations Advocate services in the capacity of Network Account Manager for managing the Florida SMMC business (Medicaid/Long-Term Care). SR PRAs develop and maintains the provider network (ancillary groups and home and community based service providers), yielding a geographically competitive, broad access, stable network that achieves objectives for unit cost performance and trend management and produces an affordable and predictable product for customers and business partners. SR PRAs evaluate and negotiate contracts in compliance with company contract templates, reimbursement structure standards, and other key process controls. Responsibilities also include establishing and maintaining solid business relationships with providers, and ensuring the network composition includes an appropriate distribution of Long-Term Care (LTC), Home & Community Based (HCBS)specialties.

Additional Job Information:

This position will be located in Miami Florida.  The goals of our LTC network team are to manage and carry out the provider network requirements for the Health Plan with the State regulator.  Provider Relations, Network and Contracting experience is a must, Microsoft Excel intermediate to advanced level is required due to the needs of network reporting.  Microsoft Access basics is a plus.  Prefer candidate to have Associate Degree or higher. Experience with provider credentialing applications, contracting and fee tables, claims knowledge, Spanish bilingual is preferred.

If you live in FL, you will have the flexibility to work remotely* as you take on some tough challenges. This position requires 25 - 50% travel in Miami region.

Primary Responsibilities:

• Job Scope and Guidelines
  • Generally work is self-directed and not prescribed
  • Works with less structured, more complex issues
  • Serves as a resource to others
  • Assesses and interprets customer needs and requirements
  • Identifies solutions to non-standard requests and problems
  • Solves moderately complex problems and/or conducts moderately complex analyses
  • Works with minimal guidance; seeks guidance on only the most complex tasks
  • Translates concepts into practice
  • Provides explanations and information to others on difficult issues
  • Coaches, provides feedback, and guides others
  • Acts as a resource for others with less experience 
• In this role you will be expected to:
  • Apply basic knowledge of provider network functions, ability to work in a fast-paced environment
  • Intermediate skill level in Microsoft programs (Teams, Outlook, Word, Excel, PowerPoint) and spreadsheet management  Microsoft Access knowledge is a plus
  • Ability to take initiative and use problem-solving skills for issue resolution
  • Depend minimally on others for instruction, guidance or direction Must be attentive to detail, work with flexibility, and have the capability of multi-tasking to meet deadlines and deliverables
  • Possess knowledge in Medicaid and Long Term Care (Home and Community Based) programs
  • Must have good communication skills; and the ability to build and retain relationships with Provider/Ancillary providers
  • Experience working with Health Plan contracts in compliance with company contract templates to ensure the network composition includes an appropriate distribution of provider spe