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Job Summary

The Provider Relations Representative develops & maintains positive relationships with physicians, providers, and practice managers within our participating provider network, including oversight & managing performance in various incentives based and/or value-based programs. Responsible for educational needs of providers and their office staff in any matters concerning provider relationships with ilumed and network service issues. Facilitates the development of a comprehensive provider network and serves as the primary contact, offering education, technical assistance and problem solving as necessary.

Essential Job Functions

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  Develop & maintain positive relationships with providers, ensure provider adherence to contractual requirements, and educate providers and office staff on topics including, but not limited to health plan operations/policies and procedures, preventative & quality outcome metrics & risk adjustment
• Responsible for understanding, developing, tracking, monitoring, and reporting on key programs performance metrics, such as STARs, HEDIS, and other quality performance measures
• Prepares for and participates in meetings with providers and provider staff and plans, creates & delivers agendas and/or presentations
• Work closely with providers & office staff to encourage membership growth & member retention
• Provide follow-up and intervention relating to provider complaints, thereby ensuring that the complaint process is appropriately handled
• Perform initial educational orientation for all newly contracted providers, within the first thirty days of participation and provide educational updates annually or as necessary with providers and office staff on changes within the Provider Manual
• Work closely with Contracting regarding provider changes, terminations, deficiencies, issues identified by providers, members, internal staff or because of reviewing internal reports
• Performs other duties as assigned

Skills and Competencies

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  Proven record of leading a team with successful outcomes.
• Proficient in Microsoft Office skills (Excel, Word, Access, etc.)
• Able to organize and lead ZOOM, Teams, WebEx, and other virtual meeting environments
• Ability to effectively communicate in English, both verbally and in writing
• Enjoys working in both individual and team settings
• Able to execute projects in a fluid and fast paced environment
• Good communication and relationship skills
• Strong analytical skills
• Attention to detail
• High level of energy

Education and Experience

• High School Graduate/Equivalent; BA / Associates degree preferred
• Knowledge of provider reimbursement, Medicare reimbursement, coding and HEDIS Measures and care gap reporting preferred
• Understanding of provider office dynamics and optimal approaches to communicating and educating providers and provider staff
• Understanding of provider reimbursements and coinciding challenges (FFS, CPT code reimbursement, etc.
• Experience in customer service/relations-like roles
• Healthcare experience highly preferred.

Physical Demands

• Potential travel required; 30%-50% per month
• Lifting, carrying, and setting up provider training materials – weighing up to 35 lbs.

Additional Information

• Must have reliable internet/wifi service
• Must abide by all HIPAA, Confidentiality & Privacy Laws
• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the job

DISCLAIMER:

Job descriptions are not meant to be all-inclusive and/or the job itself is subject to change. Nothing in this job description restricts ilumed’s right to assign or reassign duties and responsibilities to this job at any time.