Network Relations Consultant

CareMore Health; Los Angeles (CA); On-site; USD 81,000 - 121,000; Full time

Job summary

CareMore Health seeks a Network Relations Consultant to drive provider performance, including PAHAF completion, AWV and Star ratings of 4 or above. The role involves on-site relationship development with MDs, coordinating contracts and education, and resolving issues to ensure high-quality service.

Responsibilities include regular provider visits, education delivery, issue resolution, and collaboration with claims, pricing, and medical management to optimize network performance.

Qualifications

• Requires a Bachelor’s degree.
• Minimum of 3 years of customer service experience including 2 years experience as a Network Management Rep.
• Willingness to travel to worksites and other locations as necessary.

Responsibilities

• Develops and maintains positive provider relationships through on-site visits and education.
• Resolves complex provider issues and coordinates contract-related matters.
• Coordinates communications on policies, reimbursement, and provider utilization patterns.
• Conducts provider training and distributes relations materials.
• Tracks provider utilization patterns and supports provider negotiations.

Skills

Customer service

Provider relations

Communication

Education

Bachelor's degree

Job description

Job Description Summary

The Network Relations Consult is responsible for assigned network PCP performance including PAHAF completion, AWV and Star rating of 4 or above.

How Will You Make An Impact & Requirements

Network Management Consultant:

will own individual performance engagement and on-the-ground relationship development for new and existing MDs.

• Develops and maintains positive provider relationships with provider community by regular on-site visits, communicating administrative and programmatic changes, and facilitating, education and the resolution of provider issues.
• Serving as a knowledge and resource expert regarding provider issues impacting provider satisfaction, researches and resolves complex provider issues and appeals for prompt resolution.
• May be responsible for coordinating non-negotiated contracts for new and existing providers as needed.
• Researches, analyzes and recommends resolution for contract dispute, non-routine claim issues, billing questions and other practices.
• May participation in Joint Operation Committees (JOC) of larger provider groups.
• Coordinates communication process on such issues as administrative and medical policy, reimbursement and provider utilization patterns.
• Conducts seminars to support the understanding of managed care policies and procedures.
• Identifies network access and deficiencies and develops recruitment and contracting strategies.
• Coordinates and conducts provider training including developing and distributing provider relations materials.
• Responsible for providing quality, accessible and comprehensive service to the company's provider community.
• Provide assistance regarding education, contract questions and non-routine claim issues.
• Coordinates communications process on such issues as administrative and medical policy, reimbursement and provider utilization patterns.
• Coordinates prompt claims resolution through direct contact with providers, claims, pricing and medical management department.
• Identifies and reports on provider utilization patterns which have a direct impact on the quality of service delivery.
• Tracks and conduct provider refresher training.
• Researches issues that may impact future provider negotiations or jeopardize network retention.

Requirements

• Requires a Bachelor's degree
• Minimum of 3 years of customer service experience including 2 years experience as a Network Management Rep; or any combination of education and experience, which would provide an equivalent background.
• Travels to worksite and other locations as necessary.

Quality and AWV

• Consistent PCP visits focused on:
• PAHAF completion, STARS gaps closed
• HCC Re-capture rate,
• PCP referrals

Provider Education

• Model of Care
• Portal usage/training Referrals and authorizations
• New PCP on-boarding

Issue Resolution

Issue Identification & Resolution

• Claims
• Referrals and authorizations
• G&A
• The posted compensation range represents the national market average. Compensation for roles located in premium or high-cost geographic markets may fall above this range. This position is bonus eligible based on individual and company performance.**

Compensation Range

$80,819.00

to

$121,228.00

The anticipated base salary range represents the Company's good-faith estimate of the compensation it reasonably expects to pay for this position at the time of posting. Actual compensation will be determined based on factors including experience, skills, qualifications, geographic location, internal equity, and business needs.