Provider Engagement & Network Performance Lead

Superior HealthPlan; Laredo (TX); In loco; USD 56.000 - 101.000; Tempo pieno

Descrizione del lavoro

Centene is seeking a Provider Relations Specialist to maintain partnerships with contracted provider networks across South Texas. You will serve as the primary contact, triage issues, and educate providers on referrals and claims processes while driving network performance.

The role requires travel throughout Webb, Nueces, Cameron counties and beyond, with a focus on improving quality and cost utilization in managed care. Bachelor’s degree and 2+ years in a related field are required.

Competenze

• Bachelor’s degree in related field or equivalent experience.
• Two years of managed care or medical group experience, provider relations, quality improvement, claims, contracting utilization management, or clinical operations.
• Project management experience at a medical group, IPA, or health plan setting.
• Proficient in HEDIS/Quality measures, cost and utilization.

Mansioni

• Serve as primary contact for providers and act as a liaison between the providers and the health plan.
• Triages provider issues as needed for resolution to internal partners.
• Receive and effectively respond to external provider related issues.
• Investigate, resolve and communicate provider claim issues and changes.
• Initiate data entry of provider-related demographic information changes.
• Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics.
• Perform provider orientations and ongoing provider education, including writing and updating orientation materials.
• Manages Network performance for assigned territory through a consultative/account management approach.
• Evaluates provider performance and develops strategic plan to improve performance.
• Drives provider performance improvement in the following areas: Risk/P4Q, Health Benefit Ratio (HBR), HEDIS/quality, cost and utilization, etc.
• Completes special projects as assigned.
• Ability to travel locally 4 days a week.
• Performs other duties as assigned.
• Complies with all policies and standards

Conoscenze

Provider relations

Account management

Communication

Travel readiness

Formazione

Bachelor's degree in related field

Descrizione del lavoro

Centene is seeking a Provider Relations Specialist to maintain partnerships with contracted provider networks across South Texas. You will serve as the primary contact, triage issues, and educate providers on referrals and claims processes while driving network performance.

The role requires travel throughout Webb, Nueces, Cameron counties and beyond, with a focus on improving quality and cost utilization in managed care. Bachelor’s degree and 2+ years in a related field are required.