Provider Relations Specialist HYBRID

US Family Health Plan- A TRICARE Prime option; New York (NY); Hybrid; USD 60,000 - 65,000; Full time

Job summary

A leading health plan organization seeks a provider relations coordinator to serve as the liaison between the plan and healthcare providers. This role involves developing relationships, educating providers on Plan standards, and ensuring adherence to TRICARE requirements. The ideal candidate will possess strong organizational and communication skills, with a focus on enhancing provider network relationships in a hybrid work environment.

Benefits

401(k) matching

Dental insurance

Health insurance

Paid time off

Professional development assistance

Vision insurance

Qualifications

• 3-5 years of experience in health insurance or provider relations.
• Associate’s Degree Required or Bachelor’s Degree Preferred.
• Proficiency in Microsoft Office and Salesforce.

Responsibilities

• Develop and maintain relationships with the provider network community.
• Conduct provider orientation and ongoing training.
• Monitor network adequacy and respond to provider inquiries.

Skills

Organizational skills

Communication skills

Analytical skills

Data entry skills

Education

Associate’s Degree

Tools

Microsoft Office

Salesforce

Job description

JOB SUMMARY

Serves as the liaison between the Plan and our network of healthcare providers. Develops and maintains relationships with the provider network community. Responsible for educating the network on Plan standards and TRICARE requirements. Responsible for new provider orientation program and ongoing training to ensure understanding of Plan policies, programs, TRICARE requirements and contractual obligations. Monitors network adequacy and responds appropriately; collaborates with marketing/sales and family practice center staff to ensure beneficiaries needs are fulfilled. Serves as the primary point of contact to address inquiries and resolve issues; track, trend and report provider inquiries/issues to management.

RESPONSIBILITIES

• Actively communicate with prospective and contracted providers based on business needs.
• Guide prospective providers through application, credentialing, and contract process (provider onboarding).
• Conduct prospective provider in person site visits, as applicable to Plan requirements.
• Conducts new provider orientation and on-going provider trainings, as required.
• Foster and promote positive provider network relationships.
• Develop and strengthen relationships with providers/office staff and key stakeholders.
• Maintain an accurate list of contacts, including but not limited to, Managed Care, Credentialing, Claims, Contracting, Quality and Population Health executives and/or representatives.
• Manages territory, inclusive of strategic network partnerships and the Plan's family health centers and marketing staff.
• Serve as the primary point of contact, providing general instruction and support on all USFHP products, provider manual inquiries, accuracy of the provider directory, ensuring data integrity, adherence to Plan policies and Plan procedures; claims management.
• Schedule and conduct provider office/facility visits to all high-volume providers in accordance with department project plan and initiatives.
• Investigate, resolve, and respond to provider inquiries including, but not limited to, participation requirements, credentialing requirements, credentialing status, contract terms, fee schedules, claims management, reimbursement, utilization, access/availability standards, member eligibility, consult report requirements, provider payment configuration.
• Document and track inquiries received and monitor towards resolution in accordance with Plan policy and TRICARE regulations.
• Facilitate interdepartmental collaboration to resolve complex provider issues; track and trend issues.
• Partner with marketing/sales teams and participate in outreach activities/events, targeting market growth, penetration and building brand recognition.
• Prepare analytical reports of network status including gaps/access and availability.
• Monitor contract performance and network adequacy through site visits, claims and data analytics.
• Enforce quality and regulatory compliance guidelines; participate in HEDIS activities.
• Collaborate with Quality Department (HEDIS) to help reinforce Plan quality standards and increase positive patient outcomes.
• Additional inter-departmental duties as assigned.

YEARS OF EXPERIENCE

• 3 - 5 years of experience in health insurance, provider relations, provider contracting, provider network development or provider credentialing.
• Or a minimum of 5-8 years relevant work experience with an Associate’s Degree or Bachelor’s Degree in progress.

TECHNICAL SKILLS/COMPETENCIES

• Proficiency in Microsoft Office: Word, Excel, PowerPoint – Access and Salesforce
• Strong organizational skills and detail oriented.
• Excellent presentation skills.
• Excellent data entry skills.
• Ability to meet stringent deadlines and adjust priorities to meet business needs.
• Excellent communication & analytical skills.
• Medical and managed care terminology.
• Able to lift 20 pounds.

Education/Certifications/License

• Associate’s Degree Required or Bachelor’s Degree Preferred.
• Valid driver’s license.

SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER – ALL QUALIFIED APPLICANTS WILL RECEIVE CONSIDERATION FOR EMPLOYMENT WITHOUT REGARD TO PROTECTED VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.

SVCMC Inc. provides a robust benefits package that includes medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services. Employees also receive vision coverage through UnitedHealthcare Vision and dental benefits through MetLife. Basic life and disability insurance are automatically provided at no cost. All employees are eligible for commuter benefits, tuition reimbursement, and a 401(k) retirement plan with an immediate employer match that is fully vested from day one. SVCMC also offers a generous time off package, which includes vacation, 10 paid holidays, and 3 personal days. Additionally, employees have access to a comprehensive Employee Assistance Program and exclusive discounts through Working Advantage.

Job Type: Full-time

Pay: $60,000.00 - $65,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Professional development assistance
• Vision insurance

Shift:

• 8 hour shift
• Day shift

Education:

• Associate (Required)

License/Certification:

• Driver's License (Required)

Ability to Commute:

• New York, NY 10018 (Preferred)

Ability to Relocate:

• New York, NY 10018: Relocate before starting work (Preferred)

Work Location: Hybrid remote in New York, NY 10018