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Provider Relations Rep, Sr -Liverpool- Syracuse, NY at WellCare

Posted in Health Care 30+ days ago.

This job brought to you by eQuest

Type: Full-Time
Location: Liverpool, New York





Job Description:

Senior Provider Relations Representative-Syracuse, NY:

Manages physician network by developing and maintaining relationships to drive business results within a specific geographic area. Provides service and education to network physicians/providers. Achieves company targets through implementation of Network Improvement plans.

Reports to: Senior Director Provider Relations

Department:  Provider Relations

Position location: Liverpool, -Syracuse NY

Essential Functions:


  • Completes new provider orientation for all applicable product lines.

  • Conducts site visits to service providers to provides education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and review HEDIS information. Addresses RxEffect, P4P, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, etc.

  • Achieves frequency goals to establish consistent and strong relationship with provider offices.

  • Partners with local and national ancillary for appropriate vendor management and coordinates the transition of the delegated providers following a network termination.

  • Provides oversight on claims issues. Follows up with providers accordingly.

  • Monitors and supports providers using utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve and maintain regions.

  • Understands and explains fee-for-service and risk contracts, and provides reporting on provider and/or Service Fund performance.

  • Proactively strategies for membership growth and retention, through advanced communication to providers, as well as follow-up to gauge the response to that growth.

  • Ensures contract SLA’s are met, such as meeting with PCP’s and Specialists on a monthly, quarterly, or annual basis to address provider panels, after hour’s availability and EMR meaningful use.

  • Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.

  • Partners with finance to identify Medical Expense Initiatives to take actions necessary to successfully complete those initiatives, and assess progress on achieving financial goals.

  • Provides continual training to assigned providers on wellcare.com portal and other resources to assist with claims, authorizations, member benefits, etc.

  • Provides oversight of delegated functions, as applicable.

  • Handles more complex and higher volume providers.

  • Provides education, training and mentoring to newly hired or less experienced Provider Relations Representatives.

  • Assists management on special projects and/or initiatives.

  • Performs special projects as assigned.
Additional Responsibilities:


  • Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.

Candidate Education:


  • Required A Bachelor's Degree in a related field
Candidate Experience:


  • Required 3+ years of experience in Provider Relations, Network Management, Hospital Contracting or related Provider Services position demonstrated ability to perform the level of duties of the position

  • Required 1+ year of experience in Medicaid/Medicare
Candidate Skills:


  • Intermediate Demonstrated interpersonal/verbal communication skills

  • Intermediate Demonstrated written communication skills

  • Intermediate Demonstrated negotiation skills

  • Demonstrated problem solving skills

  • Demonstrated organizational skills

  • Demonstrated analytical skills

  • Intermediate Demonstrated customer service skills

  • Intermediate Knowledge of community, state and federal laws and resources

  • Intermediate Ability to represent the company with external constituents

  • Intermediate Ability to multi-task

  • Intermediate Ability to work independently

  • Intermediate Demonstrated time management and priority setting skills

  • Intermediate Other Ability to explain complicated financial terms and utilization data to physicians/staff

  • Intermediate Other Ability to understand, interpret and communicate all types of provider and regulatory contracts
Licenses and Certifications:
A license in one of the following is required:
    Technical Skills:


    • Required Intermediate Microsoft Word

    • Required Intermediate Microsoft Excel

    • Required Intermediate Microsoft Outlook
    Languages: