Provider Relations Representative - PCP

** Become a part of our caring community*
* The Provider Relations Representative is responsible for day-to-day, front-line relationship management for network providers in Humana Healthy Horizons in 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.

+ 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, including, but not limited to, required annual trainings, periodic updates to and/or reviews of Humana policies and procedures, and Humana systems training and updates

+ Support newly assigned providers with onboarding, including hosting orientation session(s)

+ Respond to assigned provider inquiries and support prompt issue resolution, including, where necessary, collaboration with appropriate enterprise business teams (ex., claims payment, prior authorizations & referrals)

+ Work with internal resources and systems (e.g., claims, reimbursement, provider enrollment) 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 (Orientation, Provider Manual, Newsletter, Program Updates, Etc.)

+ Convene regular meetings with providers, including organizing agendas, materials, meeting minutes, other team members (clinical, provider engagement), 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, such as time frames for claims dispute resolution, provider complaints, provider inquiry response, etc.

** Use your skills to make an impact*
* ** Required Qualifications*
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** Must reside in the Tidewater Region of Virginia*
* + 2+ years of health care or managed care experience working with providers (e.g., provider relations, claims education)

+ 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*
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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.

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** Travel:
** Up to 25% of the time to Humana Healthy Horizons office…