Provider Services - Provider Performance Specialist_115-2008

JOB SUMMARY:
The Provider Performance Specialist plays a key role in strengthening relationships between the health plan and its provider network by offering education, support, and guidance on performance improvement initiatives. This position collaborates closely with internal clinical and reporting teams to deliver impactful outreach focused on Star Ratings, HEDIS, care gap closure, and risk adjustment strategies. The position will be responsible for training Provider Services colleagues so all are prepared to educate and function as a resource for providers, helping them navigate performance expectations, improve documentation, and optimize quality outcomes.

KEY RESPONSIBILITIES:

• Serves as the primary provider-facing representative for quality and risk adjustment education within the Provider Services team.
• Train Provider Services colleagues to educate assigned providers on quality and risk adjustment performance improvement initiatives, understand plan tools, resources, and reporting dashboards to support assigned provider’s performance improvement activities.
• Collaborate with internal clinical, quality, risk adjustment and reporting teams to:
• Stay informed on evolving regulatory and program updates impacting provider performance.
• Align messaging and coordinate provider outreach strategies as appropriate.
• Educate provider offices on key performance programs including CMS Star Ratings, HEDIS, risk adjustment (HCC coding/recapture), and preventive care initiatives.
• Coordinate and participate in on-site, virtual, or group educational sessions with providers/office staff and internal clinical, quality and risk adjustment team members.
• Assist with responding to provider inquiries regarding performance metrics, care gap reporting, and coding best practices, escalating clinical concerns to internal partners as needed.
• Assist providers with understanding plan tools, resources, and reporting dashboards to support performance improvement.
• Support onboarding of new providers by communicating expectations around documentation, coding accuracy, and member care opportunities.
• Perform other duties as assigned.

QUALIFICATIONS:

• Strong relationship management and interpersonal communication skills.
• Ability to simplify complex quality and performance concepts for provider audiences.
• Collaborative team player who thrives in a cross-functional environment.
• Organized, detail-oriented, and comfortable managing multiple priorities and projects.
• Proficient in Microsoft Office (Excel, PowerPoint, Teams) and comfortable learning new tools and dashboards.
• Ability to travel locally or regionally to provider offices as needed.
• Must have a current driver’s license, insurance verification and reliable transportation.
• Successful completion of Health Care Sanctions background check.

EDUCATION/EXPERIENCE:

• Bachelor’s degree in Healthcare Administration, Business, Public Health, or related field preferred.
• 3 years of experience in provider relations, provider engagement, or health plan operations, ideally within a Medicare Advantage, Medicaid, or Commercial setting.
• Working knowledge of CMS Star Ratings, HEDIS, and risk adjustment programs (HCC coding, care gap closure, etc.) preferred.
• Experience collaborating with clinical teams or delivering provider education preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin