Provider Relations Representative

DOCTORS HEALTHCARE PLANS, INC.•Coral Gables, FL

About The Position

The Provider Relations Representative will exercise their duties and responsibilities with the utmost professionalism and dedication. This role involves conducting provider orientations, disseminating important provider information, performing annual site visits, overseeing provider accounts, and ensuring compliance with regulatory standards. The representative will also participate in quality management initiatives, special projects, and effectively address provider complaints and disputes.

Requirements

3 - 5 years’ experience with a Medicare Advantage Health Plan or BS/BA Degree
Commitment to the Health Plan’s vision and mission
Excellent communication skills, both in oral and written
Demonstrable knowledge of provider reimbursement methodologies applicable to Medicare Advantage Health Plans and other federal health insurance programs
Knowledge of CMS, AHCA and other federal and state current regulatory governing guidelines applicable to HMOs
Excellent organizational skills
Flexible Disposition to enable management of special projects
Excellent Customer Service Skills to enable resolution of complex and varied situations involving multiple internal and external stake holders
Ability to drive key organizational / operational initiatives

Nice To Haves

Fully Bilingual English / Spanish

Responsibilities

Conducting provider orientations of newly contracted providers within specified time frames.
Securing a signed Notice of Educational In - Service Acknowledgement Form upon completion of each provider orientation session.
Maintaining original completed copies of the Notice of Educational In – Service Acknowledgement Forms.
Disseminating the Provider Handbook / Manual, Provider Bulletins, and applicable Policies and Procedures affecting the Health Plan’s Participating Network of Providers on an “as needed” basis.
Conducting the Annual Site Visit for PCPs and High-Volume Specialists within established time frames.
Oversight of the participating provider accounts assigned by the VP of Provider Relations or their designee.
Adhering to the delineated Periodic Site Frequency Parameters for established PCPs and High-Volume Specialists.
Completing the PCP Provider Site Visit Tool for each Annual and Periodic PCP site visit conducted within their assigned service area.
Completing the Specialty Provider Site Visit Tool for each Annual and Periodic Specialty site visit conducted within their assigned service area.
Conducting Provider After Hours surveys and periodically monitoring accessibility to care to ensure it meets or exceeds CMS standards.
Ensuring all communication and training materials distributed to participating providers are up to date.
Providing assistance in coordinating the Annual Medicare Advantage Health Plan Benefit presentation dinner meetings.
Actively participating in Quality Management Program initiatives and QI special projects.
Actively participating in the implementation of special projects logistics reporting pertinent to Provider Corrective Action Plans, Provider Surveys, Provider claim dispute settlements, etc.
Effectively addressing all matters of Provider complaints and disputes presented for resolution to the VP of Provider Relations.
Maintaining an accepted and expected level of proficiency in Federal and State regulatory subject matters as mandated through CMS, AHCA and other applicable agencies governing the operations of Medicare Advantage Plans.