Provider Relations Representative

Doctors Healthcare Plans • Coral Gables, FL

6d

About The Position

The Provider Relations Representative will exercise their duties and responsibilities with the utmost professionalism and dedication. This role is responsible for conducting provider orientations, disseminating important provider information, conducting annual site visits, overseeing participating provider accounts, monitoring accessibility to care, ensuring communication and training materials are up-to-date, assisting with benefit presentation meetings, and actively participating in quality management initiatives and special projects. The representative will also address provider complaints and disputes, and maintain proficiency in federal and state regulatory subject matters governing Medicare Advantage Plans.

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.
• 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 to the network of providers on an as-needed basis.
• Conducting Annual Site Visits for PCPs and High-Volume Specialists within established time frames.
• Oversight of participating provider accounts assigned by the VP of Provider Relations or designee.
• Adhering to 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.
• Completing the Specialty Provider Site Visit Tool for each Annual and Periodic Specialty site visit.
• Conducting Provider After Hours surveys and monitoring accessibility to care to meet or exceed CMS standards.
• Ensuring all communication and training materials distributed to participating providers are up-to-date.
• Providing assistance in coordinating 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.
• Maintaining an accepted and expected level of proficiency in Federal and State regulatory subject matters as mandated through CMS, AHCA and other applicable agencies.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level