Provider Relations Representative

Parkland Health

5d•Hybrid

About The Position

The Provider Relations Representative provides business service to participating providers and serves as the primary liaison between providers and Parkland Community Health Plan (PCHP). The role also identifies and recruits new behavioral and physical health providers to complement and expand the network. The representative executes PCHP’s network development plan to support quality of care, patient experience, and avoidable-cost goals. The position requires effective communication and de-escalation skills, including maintaining positive provider relationships, handling challenging conversations professionally, addressing concerns diplomatically, and resolving conflicts while fostering collaboration and trust. The representative supports provider contracting, recruitment, onboarding, education, outreach, quality and value-based care initiatives, and regulatory compliance. The role also collaborates across PCHP, contributes to complex system-wide initiatives, and may act as a project lead.

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.
Effective communication and de-escalation skills, including the ability to maintain positive provider relationships, navigate difficult conversations professionally, address concerns diplomatically, and resolve conflicts.
Excellent contract preparation skills and in-depth knowledge of provider reimbursement.
Strong financial acumen and proficiency in 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 positive outcomes in complex situations.
Ability to gain consensus and negotiate performance improvement plans.
Excellent verbal and written communication skills, including the ability to communicate professionally across disciplines and explain complex information clearly.
Strong interpersonal and conflict-resolution skills and ability to build and maintain effective working relationships across and beyond the organization.
Excellent analytical and problem-solving skills.
Strong time-management and organizational skills, including the ability to manage multiple demands and respond to changing priorities.
Ability to write clearly and succinctly with strong attention to detail.
Proficient computer and Microsoft Office skills and ability to learn new software programs.
Knowledge of Texas Medicaid, NCQA, the Uniformed Managed Care Contract, Texas Department of Insurance, 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, ICD-10, CMS 1500 professional claims, UB ancillary, and hospital clean-claim guidelines.

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 to 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 related presentation materials.
Conduct organized meetings with assigned providers and prepare supporting materials, including meeting minutes, action plans, and memoranda.
Support and collaborate with PCHP functional areas, work on complex system-wide initiatives, and act as a 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 as needed.
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 adherence to PCHP policies, procedures, quality-improvement requirements, 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 integrity, ethical standards, and Parkland’s Mission, Vision, and Values.
Follow organizational policies, procedures, and guidelines; complete assigned training, self-appraisal, and annual health requirements on time; adhere to hybrid work schedule requirements; and attend required meetings and town halls.
Communicate ethical and legal concerns through established channels, complete work and assignments on time, respond to information requests promptly, and maintain confidentiality.
Perform other work as requested that is reasonably related to the employee’s position, qualifications, and competencies.
Identify opportunities to improve work processes and customer satisfaction; recommend improvements to a supervisor, implement them, and monitor results as appropriate.
Stay current with developments and trends in the field and integrate knowledge gained into work practices.
Maintain knowledge of applicable rules, regulations, policies, laws, and guidelines; develop effective internal controls and seek guidance as needed.