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
Licenses and Certifications: A license in one of the following is required: