Provider Relations Representative - PCP

Humana • Hampton, VA

5d • Remote

About The Position

The Provider Relations Representative is responsible for day-to-day, front-line relationship management for network providers in Humana Healthy Horizons in Virginia Medicaid Plan. This role supports provider onboarding, training, education, and inquiry/issue support and resolution. The individual in this role should have critical thinking/problem solving skills, an understanding of health plan operations, and strong interpersonal skills. This role develops and grows positive, long-term relationships with physicians, providers and healthcare systems.

Requirements

• Must reside in the Tidewater Region of Virginia
• 2+ years of health care or managed care experience working with providers (e.g., provider relations, claims education)
• Experience working with physical health providers, facilities, ancillary providers, and/or FQHCs
• Experience in provider operations, building strong relationships with provider organizations, financial/contracting arrangements, and/or regulatory requirements
• Exceptional relationship management and interpersonal skills
• Proficiency in analyzing, understanding, resolving, and communicating complex issues
• Exceptional time management and ability to manage multiple priorities in a fast-paced environment
• Thorough understanding of managed care contracts, including contract language and reimbursement
• Exceptional written and verbal communication skills
• Strong presentation and facilitation skills
• Knowledge of Microsoft Office applications

Nice To Haves

• Experience with Virginia Medicaid
• Understanding of claims systems, adjudication, submission processes, coding, and/or dispute resolution
• Understanding of service coordination, prior authorizations, and other health plan processes
• Understanding of value-based payment programs

Responsibilities

• Serve as primary relationship manager with assigned providers to ensure positive provider experience with Humana Healthy Horizons and promote network retention
• Meet regularly, both in-person and virtually, with assigned providers to conduct training and education, including, but not limited to, required annual trainings, periodic updates to and/or reviews of Humana policies and procedures, and Humana systems training and updates
• Support newly assigned providers with onboarding, including hosting orientation session(s)
• Respond to assigned provider inquiries and support prompt issue resolution, including, where necessary, collaboration with appropriate enterprise business teams (ex., claims payment, prior authorizations & referrals)
• Work with internal resources and systems (e.g., claims, reimbursement, provider enrollment) to provide the Exceptional Experience in all provider interactions
• Create provider trainings based on provider feedback, trends in claims or process changes
• Educate provider on location and content of all provider facing materials (Orientation, Provider Manual, Newsletter, Program Updates, Etc.)
• Convene regular meetings with providers, including organizing agendas, materials, meeting minutes, other team members (clinical, provider engagement), to discuss key operational, clinical, and quality related topics
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, Availity, Quality resources, and member resources
• Communicate updates on Humana's policies and procedures and Cardinal Care programmatic updates
• Coordinate periodic regional provider townhalls and/or trainings
• Attend Network Meetings/Conferences
• Ensure compliance with all Virginia managed care contractual requirements for provider relations, such as timeframes for claims dispute resolution, provider complaints, provider inquiry response, etc.

Benefits

• medical, dental and vision benefits
• 401(k) retirement savings plan
• time off (including paid time off, company and personal holidays, paid parental and caregiver leave)
• short-term and long-term disability
• life insurance

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: No Education Listed