Provider Relations Rep, Sr -Liverpool- Syracuse, NY at WellCare
Posted in Health Care 30+ days ago.
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Location: Liverpool, New York
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
- 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.
- Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.
- Required A Bachelor's Degree in a related field
- 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
- 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
A license in one of the following is required:
- Required Intermediate Microsoft Word
- Required Intermediate Microsoft Excel
- Required Intermediate Microsoft Outlook