Provider Network Associate

FLSA Status: Exempt
Department: Provider Network Management
Reports To: Director, Provider Network Management or Operations Director, MLTSS

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION
The Provider Network Associate will serve as a liaison to SCFHP’s network of providers, hospitals, sub-acute facilities and health systems, including medical groups, independent clinics, mental health professionals, and ancillary providers.  The Provider Network Associate will be an integral part of the Provider Network Management and MLTSS teams and will provide exemplary customer service and training to all providers in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.

ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Represent SCFHP in the provider community, including but not limited to, representing the department and SCFHP at internal and external meetings and events.
2. Via telephone and in person, act in the capacity of primary provider liaison and SCFHP subject matter expert by responding to and resolving complex provider questions and complaints/problems in an efficient and timely manner.
3. Assist providers to navigate SCFHP operations provider network systems, compliance and regulations.
4. Communicate clearly and concisely with providers at all levels, including administration, the business office and relevant vendors. Accurately capture and document issues and feedback. Convey information to other departments and organizational leadership when appropriate.
5. Collaborate with Provider Network Management and MLTSS team members to coordinate resolution of operational issues with internal departments and cross-departmental improvement efforts.
6. Assist with the development and monitoring of the provider network to identify issues related to network adequacy and/or access issues and take action, as needed to improve quality access to medical services and improve member satisfaction.
7. Create and deliver SCFHP provider orientation and training within established timeframes. On an annual basis, develop and execute provider communication plans including a schedule of site visits, trainings and meetings necessary to execute on the communication and training strategies.
8. Maintain knowledge of SCFHP's departmental functions and processes that enable research and identification of operational issues related to claims, authorizations, member grievances, provider disputes, and quality.
9. Build and maintain expertise and understanding of managed care, SCFHP policies and procedures and relevant regulatory requirements. Incorporate knowledge into the development of provider training and communication tools to improve compliance.
10. Create and participate in staff training. Assist with new hire training by allowing new Provider Services Representatives to shadow and observe performance and provide feedback to management.
11. Attend and actively participate in Provider Network Management and MLTSS meetings, other SCFHP operational meetings, training and coaching sessions, including off-site meetings as needed.
12. Initiate and manage process improvement projects in response to identified complex operational issues, trends or regulatory changes.
13. Perform other related duties as required or assigned.

REQUIREMENTS – Required (R)   Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Bachelor’s Degree in Social Sciences, Business, or related field, or equivalent experience, training or coursework.(R)
2. Minimum three years of experience in a managed care setting, provider organization or health policy organization. (R)
3. Ability to build and maintain professional relationships with providers. Experience in relationship management and directing a coordinated response to complex problems (R)
4. Knowledge of Medi-Cal, Medicaid and/or Medicare managed care programs (D)
5. Ability to create and deliver effective presentations and communicate effectively while leading diverse groups. (R)
6. Maintenance of a valid California driver’s license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)
7. Proficient in adapting to changing situations and efficiently alternating focus to support department operations as dictated by business needs. (R