Provider Relations Representative

Cano Health • Jupiter, FL

87d • Onsite

About The Position

The Provider Relations Representative develops and maintains service relationships with all participants (physicians, providers, and administrators) of a provider network. This role involves responding to electronic and direct inquiries from clients about policies, rates, changes, referrals, eligibility, credentialing, etc.

Requirements

• Bachelor's degree required, master's preferred (MHA or MBA), or equivalent years of experience in Health Care Administration and/or Managed Care Organization or related field.
• 8-10 years related experience and/or training or experience/education.
• Formal training in Medical Management/Utilization Management a plus.
• Managed care experience (2 years) or 4 years work experience in a provider office environment.
• Knowledge of healthcare industry - Health Plan, MSO, CMS, Federal regulations and downstream Medicare Advantage risk arrangements.
• Excellent written/oral skills and interpersonal/listening skills to interact effectively with individuals of all backgrounds, experience, and educational levels.
• Strong quantitative organizational and administrative skills.
• Ability to manipulate large databases and to produce meaningful analytical and management reports.
• Excellent Microsoft Office skills, including working knowledge of Excel and Word.

Nice To Haves

• Knowledge of HMO and MCO operations, and continuous quality and utilization/medical management techniques and operations.
• Demonstrated knowledge of CPT, ICD-10, Medicare rules, RBRVS, & HCPCS coding.
• Strong people and project management skills.
• Demonstrated ability to develop and implement new business units and service lines.
• Knowledge of Disease Management implementation models.
• Comfort in Computer applications.
• Knowledge of standardized HMO and Medicare Advantage benefit structures.
• Project Management skills and experience are preferred.
• Limited knowledge of medical terminology is preferred.
• Fluent in English and Spanish.

Responsibilities

• Establish working relationships and collaborate with providers' office staff in executing contracts and adhering to benchmarks set forth in all value-based programs.
• Work with providers and office staff to ensure compliance with PPG's requirements and expectations.
• Perform site visits to conduct outreach, education, training, and orientation sessions for providers and key administrative staff.
• Identify value-based provider offices and vendors to be contracted by health plan.
• Monitor practice performance to ensure compliance with all contractual agreements, identify any barriers, and make recommendations for corrective action plans and other interventions as required.
• Review departmental and personal goals on an ongoing basis with VP/ Director of Provider Relations.
• Follow all applicable federal/state regulations with respect to Confidentiality and HIPAA, among others.
• Mandatory attendance at quarterly membership meetings, monthly orientation seminars, and monthly physician networking events which occur outside of regular business hours.
• Interact in a professional, respectful, and helpful manner.
• Generate call and visit reports daily and document all practice encounters.
• Conduct orientations/re-orientations.
• Monitor encounter data and act upon issues.
• Update provider offices on policies & procedures.
• Maintain network matrices & directories, including QNXT Provider database.
• Adjustments, deductions, verification, and distribution of Capitation checks/referral forms, including preparation of newsletter.
• Identify trends in physician activity rather than react to occurrences.
• Prepare and mail new physician contracts and follow-up upon approval from Membership Committee.
• Credentialing as required by the client.
• Collect and present new physician applications to Membership Committee.
• Negotiate one-time rate for out-of-network providers and prepare documentation.
• Perform weekly review of QNXT Explanation of Benefits reports to ensure proper adjudication utilizing Medicare rules and IPA contract terms.
• Provide yearly update of provider manual.

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree