Provider Network Development Representative
AlohaCare - Honolulu, HI

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Serves as primary liaison between network participating providers and the Plan. Scope of responsibility includes, but is not limited to: regular visitation to participating provider office(s); initiating new provider agreement contacts and associations; conducting educational sessions (accomplished through in-service, workshops, and one-on-one meetings); claims issue coordination; development of materials to assist providers; provider contracts and file maintenance; and network listing maintenance.

Primary Duties & Responsibilities:
  • Communicate with providers via phone, email, letters, fax and personal visits in a positive and customer focused manner resulting in improved perception and satisfaction
  • Identify opportunities for process improvements that impact providers
  • Propose process improvements that enhance provider and customer satisfaction
  • Promote AlohaCare
  • Initiate conversations that sell AlohaCare to providers, customers, and the community
  • Demonstrate superior knowledge regarding claims, referral/auth/notification process, formulary, benefits, contracts, fees and other provider issues
  • Respond to provider inquiries, complaints, etc. immediately
  • Assess the provider network to develop recruitment strategies
  • Assess the need to do a facility site review based on our observations during provider visit
  • Assess provider operational procedure to identify training needs
  • Assess provider complaints or questions and determine the course of action to bring them to resolution
  • Participate in provider events
  • Give input and feedback at weekly department meetings, public relations meetings and workgroups
  • Participate in corporate priority project teams like EQRO, URAC accreditation, etc.
  • Investigate provider claim issues and develop an appropriate resolution
  • Research provider profiles including claim, complaints, grievances, and appeals history
  • Analyze organizational impact of fee increases, contract changes, etc
  • Identify AlohaCare business needs in relation to contracting with new providers
  • Review provider contract conditions, agreements, stipulations, requirements, etc.
  • Identify and analyze provider trends including demographic availability, perception and satisfaction levels, unique profiles, etc
  • Update and maintain a current and accurate provider directory
  • Streamline workflows
  • Expeditiously analyze claim and reimbursement issues
  • Propose resolution to provider inquiries, complaints, etc.
  • Solicit feedback from key players
  • Analyze business needs for providers and recruit targeted providers
  • Immediately alert team of provider dissatisfaction, identify issues that affect provider retention and identify “at-risk” providers
  • Develop strategies to retain providers while enhancing their perception and satisfaction
  • Organize and conduct provider trainings to enhance provider perception and satisfaction and reduce provider grievances.
  • Present interdepartmental trainings for provider related processes and solicit input to ensure appropriateness of training & provider education materials
  • Assist in developing all provider communications including the provider manual, provider quick notes, website, newsletters, provider bulletins, provider fax blasts, etc.
  • Assist in developing provider training materials
  • Alert team of any provider issues that impact AlohaCare
  • Survey providers
  • Complete provider visit summaries
  • Communicate in a customer-focused manner either via telephone, print, or in person
Required Competencies and Qualifications:
  • High School Diploma
  • Significant managerial & leadership skills & experience in building provider relations
  • Ability to make decisions
  • Excellent customer service skills
  • Ability to give input in improving product or processes and work independently
  • Outcome focused and deadline driven, accurate, committed to excellence.
  • Demonstrates corporate core values.
  • Knowledge of basic office equipment/computer systems
  • current valid Hawaii driver’s license along with access to an insured vehicle is required.

Required Licensure / Certification:
  • Conflict Resolution training or certification
  • Account Management training or certification
Preferred Competencies and Qualifications:
  • Bachelor’s Degree with relevant coursework in business management, communications, sales, and contracts
  • Experience working with Medicare/Medicaid
  • Knowledge and working experience with Long Term Care Plans
  • Understanding of claims analysis and managed health care, Medicare, provider contracting, providers’ billing practices and selling experience is highly desirable.

AlohaCare - 15 months ago - save job - block
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