Provider Relations Representative

Imperial Health Plan of California, Inc.; United States; On-site; USD 85,000 - 115,000; Full time

Job summary

Imperial Health Plans is seeking a Provider Network Administrator to manage provider relations, negotiate fees, and support network adequacy in the North Bay, California area. The role interfaces with providers, brokers, and health plans to resolve issues and ensure service compatibility with contractual requirements.

Responsibilities include onboarding providers, addressing provider concerns, maintaining compliance documents, and collaborating with departments to assign qualified providers

Job description

Must reside in the North Bay, California area (Marin, Napa, Solano or Sonoma County).

Job Description

JOB TITLE: Provider Network Administrator FLSA STATUS: Exempt

DEPARTMENT: Provider Network Management

REPORTS TO: Sr. Provider Network Administrator

JOB SUMMARY: Maintains a successful working relationship between Imperial Health Plans, network providers, and partner health plans through a full range of provider relations and service interactions to ensure network adequacy, and provider relations. Identify and communicate operational issues raised by providers, respond to customer complaints, customer satisfaction surveys and provider questions, and research and resolve accounts payable issues. Routinely negotiate cost effective fees for single services, confirm service capability and educate providers on contract expectations, processes, and paperwork. Comprehend detailed knowledge of Imperial's requirements in order to adapt agreements, contractual requirements and fee agreements to the specific situation. Must be able to routinely evaluate and analyze the most beneficial solution for Imperial and our network providers in a variety of circumstances.

Essential Job Functions

• Complete required Provider Office Face-to Face Visitation (daily, weekly, monthly) as assigned or predetermined by department management.
• Assess and resolve specific provider concerns, developing and implementing solutions that are beneficial to providers, Imperial Members and Imperial.
• Maintain network adequacy. Lead efforts to obtain letter of agreements as necessary.
• Onboard new providers within 10 business days. Train providers on an annual basis.
• Assess and respond to leads generated by brokers, providers, and customers.
• Negotiate fees that align provider needs and Imperial business objectives. Educate providers on fee structures to ensure collaborative agreement and understanding of Imperial Services and the fees associated with them.
• Staff Provider Relations Telephone Queue, adequately respond to and resolve incoming calls in the appropriate manner.
• Respond to Customer Satisfaction Surveys and Customer Complaints within the required time frame through investigation and problem solving that results in positive outcomes.
• Provide explanations and information to others on topics within area of expertise.
• Proactively review and maintain provider compliance documents to ensure active status within provider network.
• Collaborate with other departments to assign qualified providers to orders within the contractually allowed mileage radius of the patient's home zip code.
• Maintains regular and consistent attendance.
• Adheres to Compliance Plan and HIPAA regulations.

Marginal Job Functions

• Takes on special projects as needed.
• Performs other duties as assigned.

Behavioral Expectations

• Continuous Learning:
• Attends staff meetings as required.
• Attends appropriate training, seminars and workshops as required
• Customer Focus:
• Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations and IMAS's Standards of Conduct.
• Fosters appropriate communication and relations with Supervisor, co-workers and other staff.
• Quality/Process Improvement/Safety
• Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.
• Supports and demonstrates safety throughout all duties performed.
• Follows established policies and procedures and understands and complies with all regulators standards set forth by governing entities.

Education/Experience

POSITION REQUIREMENTS

High school graduate or equivalent.

Bachelor's Degree (or higher) in Business, Marketing, Communications or healthcare related field

3+ years of related experience in provider relations, network management, customer service, contract negotiations, account services and/or account management, etc. (or High School Diploma /GED and 3+ years of related experience)

Skills/Knowledge/Ability

• Must reside in the County where work is assigned
• Microsoft Office Suite (Word, Outlook, Excel
• Knowledge of negotiating rates and managing subcontractor relationships
• Knowledge of Medicare and Medical terminology (preferred)
• Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to residents and staff.
• Willingness and ability to follow written and verbal direction in English.
• Willingness and ability to maintain appropriate level of confidentiality and privacy.
• Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.
• Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.
• Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.
• Ability to effectively prioritize items/tasks as required.
• Willingness and ability to take initiative and be a self-starter.
• Willingness and ability to understand and comply with Federal, State, and local regulations.

Licensure/Certificate/Training

Driver's License – must have reliable transportation with automobile insurance