Provider Relations Representative - PCHP

Parkland Health•Unity, ME

7d•Hybrid

About The Position

The Provider Relations Representative serves as the primary liaison between Parkland Community Health Plan (PCHP) and its participating providers, delivering business support and identifying providers to expand and complement the behavioral and physical health network. The role executes PCHP’s network development plan to improve quality of care and patient experience while reducing avoidable costs. The representative works on provider recruitment, onboarding, education, outreach, claims and reimbursement issue resolution, contract negotiations, and network access. The position also supports quality improvement and value-based care programs, collaborates with PCHP functional areas on complex initiatives, and may serve as a project lead. Effective communication and de-escalation are essential to maintaining productive provider relationships, handling challenging conversations, and resolving conflicts professionally. The role ensures work complies with applicable regulatory, accreditation, and contractual requirements; promotes a culturally welcoming and inclusive environment; maintains confidentiality and ethical standards; and completes other reasonably related duties as requested. The position adheres to hybrid work schedule requirements.

Requirements

High school diploma or equivalent.
Five years of provider support, education, negotiations, relationship management, or contracting experience.
One year of behavioral health experience.
Valid Texas Class C Driver's License.
Excellent contract preparation skills and in-depth knowledge of provider reimbursement.
Strong financial acumen and proficiency analyzing and interpreting financial trends in provider contracting.
Advanced knowledge of network development strategies, clinical integration, and accountable value-based care principles.
Proficient negotiation skills, including engaging providers, advocating for mutual agreements, and influencing outcomes in complex situations.
Ability to gain consensus and negotiate performance-improvement plans.
Excellent verbal and written communication skills, including communicating professionally across disciplines and explaining complex information clearly.
Strong interpersonal and conflict-resolution skills and ability to establish and maintain effective working relationships with providers and others.
Excellent analytical and problem-solving skills.
Strong time-management and organizational skills, including managing multiple demands and rapidly changing priorities.
Ability to write clearly and succinctly with attention to detail.
Proficient computer and Microsoft Office skills and ability to learn new software.
Knowledge of Texas Medicaid, NCQA, the Uniformed Managed Care Contract, the Texas Department of Insurance, the Office of the Inspector General, the Uniform Managed Care Manual, and other state agencies involving claims and Fraud, Waste and Abuse programs.
Knowledge of CPT codes, ICD-10, CMS 1500 professional claims, UB ancillary, and hospital clean-claim guidelines.
Ability to establish and maintain positive provider relationships, navigate challenging conversations professionally, address concerns diplomatically, and resolve conflicts while fostering collaboration and trust.

Nice To Haves

Bachelor's degree in a healthcare-related field.
One year of Texas Medicaid experience.

Responsibilities

Research and resolve claims-processing workflow, quality-improvement process, and provider-reimbursement issues.
Use analytic tools to track health risks and compliance and support contract negotiations.
Recruit providers to ensure network adequacy and resolve network access gaps.
Conduct provider onboarding, education, and outreach to support adoption of and compliance with PCHP quality management and accountable value-based care programs.
Provide provider onboarding and orientation, including developing presentation materials.
Conduct organized meetings with assigned providers and prepare supporting materials such as meeting minutes, action plans, and memoranda.
Support and collaborate with PCHP functional areas, work on complex system-wide initiatives, and act as project lead.
Integrate health literacy principles into communications with members and providers.
Support strategies that meet clinical, quality, and network improvement goals.
Promote the use of health information technology to support and monitor health and social interventions and make data-driven recommendations.
For staff in clinical roles, foster collaborative relationships with members and/or providers to promote evidence-based practices and care coordination.
Conduct ongoing education and outreach to support adoption of and compliance with PCHP policies, procedures, quality-improvement, and value-based care programs.
Ensure work complies with regulatory and accreditation standards and contractual requirements.
Promote a culturally welcoming and inclusive work environment and uphold Parkland's mission, vision, values, and ethical standards.
Adhere to organizational policies, procedures, and guidelines; complete assigned training, self-appraisal, and annual health requirements on time; and attend required meetings and town halls.
Recognize and communicate ethical and legal concerns through established channels.
Independently complete work, projects, and assignments on time and respond to information requests promptly while maintaining confidentiality.
Perform other work reasonably related to the employee’s position, qualifications, and competencies.
Identify opportunities to improve work processes and customer satisfaction; recommend, implement, and monitor improvements as appropriate.
Keep current with developments and trends in the field and integrate gained knowledge into work practices.
Maintain knowledge of applicable rules, regulations, policies, laws, and guidelines; develop effective internal controls and seek guidance as needed.