The Provider Relations Representative I is responsible for assistance to and support of the Provider Relations staff. Additionally, this position is the back-up for internal/external issues concerning Provider Relations, when the Provider Relations Representative II’s are unavailable, including provider education and support and resolution of provider issues.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
QUALIFICATIONS AND REQUIREMENTS : To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- Updates monthly membership list to ensure that each PCP has current membership roster in a timely fashion (monthly recurring process).
- Identifies out-of-network providers for services not available in network.
- Completes preparation and negotiation of LOAs for out-of-network providers for services not available in network or for continuity of care; faxes fully executed LOAs to providers.
- Coordinates communication to Plan’s other departments to ensure access to care and contract configuration for LOAs for out-of-network arrangements.
- Reviews contracts for submission, completes credentialing check list assuring that all supporting documents are attached and current; keeps log of those submitted.
- Coordinates New Office Orientations process for re-credentialing cycle.
- Utilizes service guidelines, maintains network stability as it relates to physician/provider terminations and panel closing by primary care physicians.
- Works closely with other departments in the maintenance of Provider Directory.
- Manages provider demographic information changes (tax identification numbers, new addresses etc.) and resolves identified problems.
- Negotiates contracts with specialists to support network adequacy and enhance network.
- Provides education and support to providers.
- Resolves provider issues, including claims research, root cause analysis and resolution of system load issues or provider billing errors. Re-contracts as necessary.
- Coordinates with other departments to resolve provider issues.
- Abides by all compliance requirements for the Department of Insurance (DOI), Agency for Health Care Administration (AHCA) and the Centers for Medicare and Medicaid Services (CMS) as these apply to the Provider Relations Department activities.
- Performs other duties as assigned.
EDUCATION and/or EXPERIENCE: An undergraduate degree from an accredited institution of higher learning required; minimum of one year of experience in the managed care industry with a focus on contracting preferred; or an equivalent combination of education, training and experience.
NECESSARY KNOWLEDGE, SKILLS AND ABILITIES: Ability to: work from designated office for collaborative/interactive fulfillment of duties; concentrate in an open-office “cubicle” environment; appropriately and directly interact with other staff members and/or outside associates; perform telephone and/or computer work for extended periods of time; operate office equipment such as computer, telephone, and copy/scan/fax machine; attend and participate in meetings via phone, computer, or in person.
Ability to navigate and master proprietary software programs. Able to read and interpret documents. Proficient in MS Office with basic computer and keyboarding skills. Excellent oral and written communication skills including good grammar, voice and diction. Ability to formulate and articulate persuasive dialogue and to understand and convey complex financial information to providers.
LICENSING AND CERTIFICATION: None required for this position.
REQUIRED TRAVEL: Availability for occasional ground and air travel may be required.
PHYSICAL DEMANDS: The physical demands described here are representative of those that should be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to sit.
The employee frequently is required to manipulate or use objects, equipment, tools, and/or controls.
May require specific vision abilities to perform this job.
Ability to lift, carry or exert items or objects of reasonable weight.
WORK ENVIRONMENT : The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Attendance at employer worksite is an essential job requirement.
The noise level in the work environment is usually moderate.
For the most part ambient room temperatures, lighting and traditional office equipment as found in a typical office environment.
ADDITIONAL INFORMATION: The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.
The duties listed above are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment to the position.
We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.