Provider Relations Representative - PCP

Provider Relations Representative

The Provider Relations Representative is responsible for day-to-day, front-line relationship management for network providers in Humana Healthy Horizons and Virginia Medicaid Plan. This role supports provider onboarding, training, education, and inquiry/issue support and resolution. The individual in this role should have critical thinking/problem solving skills, an understanding of health plan operations, and strong interpersonal skills. This role develops and grows positive, long-term relationships with physicians, providers and healthcare systems.

Responsibilities include:

• Serve as primary relationship manager with assigned providers to ensure positive provider experience with Humana Healthy Horizons and promote network retention
• Meet regularly, both in-person and virtually, with assigned providers to conduct training and education
• Support newly assigned providers with onboarding, including hosting orientation session(s)
• Respond to assigned provider inquiries and support prompt issue resolution
• Work with internal resources and systems to provide the Exceptional Experience in all provider interactions
• Create provider trainings based on provider feedback, trends in claims or process changes
• Educate provider on location and content of all provider facing materials
• Convene regular meetings with providers to discuss key operational, clinical, and quality related topics
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, Availity, Quality resources, and member resources
• Communicate updates on Humana's policies and procedures and Cardinal Care programmatic updates
• Coordinate periodic regional provider townhalls and/or trainings
• Attend Network Meetings/Conferences

Ensure compliance with all Virginia managed care contractual requirements for provider relations.

Required Qualifications:

• Must reside in the Tidewater Region of Virginia
• 2+ years of health care or managed care experience working with providers
• Experience working with physical health providers, facilities, ancillary providers, and/or FQHCs
• Experience in provider operations, building strong relationships with provider organizations, financial/contracting arrangements, and/or regulatory requirements
• Exceptional relationship management and interpersonal skills
• Proficiency in analyzing, understanding, resolving, and communicating complex issues
• Exceptional time management and ability to manage multiple priorities in a fast-paced environment
• Thorough understanding of managed care contracts, including contract language and reimbursement
• Exceptional written and verbal communication skills
• Strong presentation and facilitation skills
• Knowledge of Microsoft Office applications
• You are field based in Virginia and requires frequent travels to provider and Humana locations

Preferred Qualifications:

• Experience with Virginia Medicaid
• Understanding of claims systems, adjudication, submission processes, coding, and/or dispute resolution
• Understanding of service coordination, prior authorizations, and other health plan processes
• Understanding of value-based payment programs

Additional Information:

• Must reside in the Tidewater Region of Virginia
• Workstyle:
  This is a remote position that will require you to travel.
• Travel:
  Up to 25% of the time to Humana Healthy Horizons office in Glen Allen, VA for collaboration and face to face meetings as well as field interactions with staff, providers, members, and their families.
• Workdays and
  
  Hours:
  
  Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).
• Language Assessment Statement:
  Any Humana associate who speaks with a member in a language other than English must take a language proficiency assessment, provided by an outside vendor, to ensure competency. Applicants will be required to take the Interagency Language Rating (ILR) test as provided by the Federal Government.

Work at Home Requirements:

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

At minimum, a download speed of 25 Mbps and an upload…