Provider Relations Representative ; Hybrid

Resp & Qualifications

PURPOSE: This role enables a seamless provider experience serving as a primary liaison with stakeholders within Health Services and across the company. Provides communication, education, issue/dispute resolution and support of managing all of Care First's contracted in‑network providers including independent professional practices, health systems, hospitals, and ancillary providers across all lines of business. This position will be assigned to providers in Washington DC area in support of Basic Health Plan and/or Medicaid products.

• Establishes and maintains relationships with providers and key stakeholders, by ensuring regular communication and timely problem resolution. Leverages provider relationships to drive and influence provider behavior towards favorable outcomes in support of corporate initiatives and positive member interactions.

• Provides ongoing and targeted training and education to provider community ensuring they can successfully utilize electronic tools, navigate provider portal, follow established processes and procedures. Partners with Provider Training and Education Department to educate providers ensuring they are engaged in the value of our programs in support of positive member interactions.

• Provides research, resolution and support for escalated service‑related issues, using expertise and coordinates between multiple parties across Care First. Identifies and resolves root cause, either independently or through formal resolution processes. Offers timely response to providers, management, and other internal customers via virtual or face‑to‑face visit, correspondence, e‑mail, and/or phone as appropriate.

• Supports network projects and outreach initiatives that must be special handled by Provider Relations in order to mitigate risk to Care First, supplement existing technology, maintain critical operations, support corporate initiatives including but not limited to provider experience scores, STAR ratings, HEDIS measures, and CAHPS program.

Education Level: Associate's Degree OR in lieu of an Associate degree, an additional 2 years of relevant work experience is required in addition to the required work experience.

Experience:

• 2 years experience with Care First computer systems (or comparable technology platforms), networks, products, policies, and procedures, including experience with providers, training, customer service, and claims processing.

• Bachelor's Degree in business, healthcare administration or related industry.

• Working knowledge of provider billing and coding mechanisms, including special pricing, medical terminology, CPT coding and CMS‑1500 or CMS UB
  -04 claim formats.
• Knowledge of managed care industry legislated and regulated requirements, health care financial matters and third‑party payment methodologies.
• Previous experience working either at Care First, an insurance plan, a hospital or a physician hospital organization (PHO).
• Understanding of contractual documents and ability to effectively communicate terms to providers.
• Ability to work effectively using Microsoft Excel, Microsoft Access, Microsoft PowerPoint and Microsoft Word.
• Ability to determine priorities and meet deadlines. Self‑motivation, and the ability to work independently and manage competing priorities in order to meet the needs of varying stakeholders and comply with varying mandated deadlines.
• Written and verbal communication including excellent customer service skills.
• Problem‑solving ability, critical thinking, and analytical skills.
• Ability to help navigate, de‑escalate, and resolve interpersonal conflicts that can arise in client‑facing roles.
• Effective presentation skills with ability to facilitate meetings, presenting information, and public speaking.
• Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence. Must be able to effectively communicate and provide positive customer service to every…