Provider Operations Representative

Position Summary: 

Responsible for fostering strong provider relationships through targeted engagement and ongoing education to the provider network in assigned market areas by performing the following duties. 

Essential Duties and Responsibilities

1. Engage in open face-to-face dialogue with physicians to communicate updated and educate on important issues.
2. Facilitate effective problem resolution between Prospect and Provider.
3. Ensure all assigned providers are compliant with company-wide initiatives including, but not limited to, Encounter Data, membership growth and MLR targets. 
4. Educate providers about program details and implement workflows to achieve positive outcomes.  
5. Monitor and report performance metrics monthly and develop action plans for non-compliant providers.
6. Organize and lead Office Manager Meetings for assigned network physicians and develop plans to ensure high level of attendance. 
7. Identify management opportunities with IPAs and groups, coordinating leads for senior management review and consideration.  
8. Collaborate with network hospitals to identify and recruit new PCPs and high-volume hospital admitters.
9. Maintain familiarity of all Medicaid and HMO Plan Network Requirements.
10. Analyze gains and losses to develop specific action plans to drive positive results for membership growth.
11. Provide tactical operations support to assigned groups including data integrity, communications, and relationship management.
12. Prepare and deliver presentations with providers, provider staff, and/or physician leadership during monthly operational meetings.

1. Track, monitor, and report on key program performance metrics, such as utilization and quality.  
2. Conduct root cause analyses and resolutions for provider concerns, grievances, claims, and care delivery.
3. Research issues impacting provider negotiations and network retention.
4. Document site visits and results for NCQA compliance. 
5. Ensure provider compliance with NCQA requirements regarding availability and access and evaluate standards to ensure they address the requirements outlined by NCQA.
6. Review claims reports, collaborating with providers to improve submissions and data accuracy to ensure accurate claim adjudication.
7. Acknowledge any grievances and complaints within 1 business day of notice and resolve within 30 days.
8. Educate providers on policies and procedures related to referrals, claim submissions, website usage, EDI solutions and other relevant topics.

 This job description in no way states or implies that these are the only duties performed by the employee occupying this position.  Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications: 

• Must have Bachelor’s degree.
• Previous HMO/IPA Operations experience preferred.
• 3-5 years of experience in the healthcare/insurance industry.
• Knowledge of Word and Excel.
• Must possess a valid Driver's License.

Skills and Abilities: 

• Verbal and written communication skills.
• Ability to speak clearly and concisely. 
• Must be detail oriented and able to work independently in a fast-changing environment. 
• Strong understanding of managed care and healthcare operations.
• Time management skills. 
• Proficiency in analyzing, understanding, and communicating financial trends. 
• Ability to manage multiple priorities within a fast-paced environment. 

Work Schedule:

Community Care Plan is currently following a hybrid work schedule. The company reserves the right to change the work schedules based on the company needs.

Physical Demands: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.  While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear.   The employee is frequently required to stand, walk, and sit. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment: 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity and inclusion.