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Provider Relations Specialist

Position Summary
A Provider Relations Specialist is responsible for working with CCHP’s provider network to support the goals of the organization. Maintains a positive and effective relationship with providers as they serve the health care needs of health plan members. Serves as internal agent in the health plan to assist the provider in addressing policy questions or operation issues. This critical member of the Provider Network Management team will manage and resolve a portfolio of cases with medical offices and other healthcare providers.

Essential Duties & Responsibilities
Under leadership of Provider Network Management, provides customer support to providers on behalf of CCHP.
In coordination with Provider Network Management, acts as liaison between providers and health plan
Travel to provider offices and participate in provider events and work in a collaborative effort with CCHP’s Sales and Marketing Travel to provider offices with the use of personal car, taxi, rider app (ex. Uber), or public transportation will be reimbursed to the employee. Parking fees are reimbursed when a personal car is used in addition to fuel to and from customer visits excluding commute from and to the office.
In coordination with internal stakeholders, responds to electronic and direct inquiries from providers about policies, referrals, eligibility, claims issues,
Supports Provider Network Manager with daily maintenance of providers and provider directories.
Verifies and maintains accurate provider
Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise
Participates in managed care delegated credentialing audits; conducts internal and external file audits from our medical groups and direct CCHP
Prepares and submits reports as directed or required, including but not limited to provider directories, printed and web versions, DMHC and CMS regulatory reporting.
Identify and flag adverse information from provider application materials for conducting special follow-up
Manage all incoming communications from current healthcare providers via inbound phone calls and emails, researching and resolving current claims cases and communicate results
Make outbound calls to obtain required information for claims management or re- consideration
Help identify root causes of claims payment errors
Collaborate with other departments and/or providers in successful resolution of claims related issues
Generate and develop reports which include but not limited to root causes of claims payment issues
Ensure all compliance requirements are satisfied and that all payments are made against company practices and procedures
Accepts and performs other duties as assigned

Qualifications
Preferably, undergraduate degree in health care administration, business or a related field and or any equivalent combination of education, industry training and directly related health care work experience
Understanding of managed health care delivery systems, medical terminology, operations, and HMO regulations
Demonstrates analytical and decision making skills
Ability to identify issues, recommend and implement solutions
Excellent verbal and written communication skills
Communicates effectively and collaboratively with physicians, health care providers or external/regulatory agencies
Flexibility, adaptability, problem solving capability, creativity, initiative, team player skills, multitasking ability, organized, and strong work ethic
Strong customer service skills. Ability to establish and maintain productive business relationships, manage conflict and negotiate solutions
Time management and organizational skills, including the ability to prioritize concurrent projects and activities, meet deadlines and work under time constraints
Proficiency in Word, Excel, and Access
Professional in manner and appearance, outstanding interpersonal skills, positive outlook, flexibility
Team player, energetic, dynamic, outgoing personality, and friendly
Knowledge of medical terminology preferred
Medical record and data collection skills required
Physical requirements
Able to lift up to 30 pounds
Use proper body mechanics when handling equipment
Standing, walking and moving 50% of the day.
Compliance requirements
Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.

Base Pay Scale
Starting at $24.76-$32.96 per hour.
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.

Time:  Full time
Salary:  Hourly
Category:  Network management

Updated: 9/19/2024 11:36:26 AM