Provider Relations Representative

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Provider Relations Representative

Provider Network Manageme Pasadena, CA, US

2 days ago Requisition

Salary Range: $70,000.00 To $74,000.00 Annually

Must reside in Shasta County, California

JOB DESCRIPTION

JOB TITLE:

Provider Network Administrator FLSA STATUS:
Exempt DEPARTMENT:
Provide Network Management

REPORTS TO:

Sr. Provider Network Administrator

JOB SUMMARY:

Maintains a successful working relationship between Imperial Health Plans, network providers, and partner health plans through a full range of provider relations and service interactions to ensure network adequacy, and provider relations. Identify and communicate operational issues raised by providers, respond to customer complaints, customer satisfaction surveys and provider questions, and research and resolve accounts payable issues. Routinely negotiate cost effective fees for single services, confirm service capability and educate providers on contract expectations, processes, and paperwork.

Comprehend detailed knowledge of Imperial’s requirements in order to adapt agreements, contractual requirements and fee agreements to the specific situation. Must be able to routinely evaluate and analyze the most beneficial solution for Imperial and our network providers in a variety of circumstances.

ESSENTIAL JOB FUNCTIONS:

• Complete required Provider Office Face-to Face Visitation (daily, weekly, monthly) as assigned or predetermined by department management.
• Assess and resolve specific provider concerns, developing and implementing solutions that are beneficial to providers, Imperial Members and Imperial.
• Maintain network adequacy. Lead efforts to obtain letter of agreements as necessary.
• Onboard new providers within 10 business days. Train providers on an annual basis.
• Assess and respond to leads generated by brokers, providers, and customers.
• Negotiate fees that align provider needs and Imperial business objectives. Educate providers on fee structures to ensure collaborative agreement and understanding of Imperial Services and the fees associated with them.
• Staff Provider Relations Telephone Queue, adequately respond to and resolve incoming calls in the appropriate manner.
• Respond to Customer Satisfaction Surveys and Customer Complaints within the required time frame through investigation and problem solving that results in positive outcomes.
• Provide explanations and information to others on topics within area of expertise.
• Proactively review and maintain provider compliance documents to ensure active status within provider network.
• Collaborate with other departments to assign qualified providers to orders within the contractually allowed mileage radius of the patient's home zip code.
• Maintains regular and consistent attendance.
• Adheres to Compliance Plan and HIPAA regulations.

MARGINAL

JOB FUNCTIONS:

Takes on special projects as needed.

Performs other duties as assigned.

BEHAVIORAL EXPECTATIONS:

• Attends staff meetings as required.
• Attends appropriate training, seminars and workshops as required
• Customer Focus:
  • Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations and IMAS’s Standards of Conduct.
  • Fosters appropriate communication and relations with Supervisor, co-workers and other staff.
• Quality/Process Improvement/Safety:
  • Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.
  • Supports and demonstrates safety throughout all duties performed.
  • Follows established policies and procedures and understands and complies with all regulators standards set forth by governing entities.

POSITION REQUIREMENTS:

EDUCATION/

EXPERIENCE:

High school…