Description

Salary: $74,023 - $107,333

Job Summary

The primary objective of this position is to lead the service, communication, and management of provider relationships in support of strategic organizational objectives. Lead Provider Relations Representatives are responsible for developing the provider network through contract negotiations, fostering relationships, and ongoing support. They are responsible for various activities including advocacy, appealing, recruiting, contracting, education, maintenance, and enhancement of provider participation and satisfaction.

The Lead Provider Relations Representative specializes in handling complex providers such as large medical groups, or those requiring extensive education on managed care concepts. The Lead is responsible for organizing outreach campaigns, coordinating the deliverables of the team, and monitoring progress toward goals. In addition, the Lead serves as an experienced resource and advisor for Provider Relations Representatives while assisting the Provider Relations Manager and leadership team.

Duties and Responsibilities

• Serves as the primary contact in the Provider Relations department for all assigned complex provider partners, including large medical groups.

• Provides guidance, support, and mentorship to Provider Relations Representatives within assigned territories.

• Conducts regular team meetings to review updates, exchange best practices, and address any challenges.

• Fosters a positive and collaborative team culture dedicated to accomplishing organizational goals and delivering outstanding service to provider partners.

• Coordinates provider contracting and retention efforts, conducts both on-site and off-site visits, delivers orientation sessions, and provides continuous education and training to complex providers and large medical groups

• Proficiently interprets contractual terms and ensures provider comprehension of such terms, including monitoring provider performance and compliance with contractual obligations, quality standards, and regulatory requirements.

• Advocates on behalf of clinic systems and sensitive providers, investigates complex provider issues, formulates recommendations for resolution, drafts responses, and documents all communication.

• Coordinates outreach campaigns, ensuring team deliverables are met and progress towards goals is tracked effectively.

• Stays up to date with changes in CenCal Health policies, practices, and resources to strategize outreach efforts to effectively communicate relevant changes to each provider type

• Coordinates internal and external training sessions and notifications for providers, including new messaging campaigns, organizational initiatives, and new programs or operational changes that impact providers

• Serves as team lead within their designated provider territory. In collaboration with their territory Provider Relations Representative, assists in investigating complex provider issues including preparing recommendations for resolution, drafting responses, and documenting all communication

• Develops educational, promotional, and presentation materials and publications for providers and the public, distributing them as necessary. Creates presentations, prepares materials, coordinates joint operations meetings, and evaluates effectiveness of educational efforts

• Lead special projects, ensuring compliance with regulatory responsibilities, and make recommendations for improvement of all procedures and systems at CenCal Health

•  Monitors key performance indicators (KPIs) for the provider relations team and initiates operational changes to ensure performance is achieved.

• Analyze data and generate reports on provider satisfaction, network adequacy, claims processing, and other relevant metrics.

• Identify areas for improvement and implement strategies to enhance provider satisfaction, streamline processes, and optimize network performance.

• Contributes to the development of Provider Bulletin articles, and provider manual revisions.

• Provides back up to the Provider Services Phone Queue to ensure customer service metrics are met

• Possesses in depth knowledge on the restricted CenCal Health Provider Portal and advises on system enhancements as provider advocates. Additionally, conducts user testing on enhancements and develops education outreach plan prior to deploying system changes

• Performs other duties as assigned by the Provider Relations Manager or Director

Qualifications

Knowledge/Skills/Abilities

• Excellent oral and written communication skills

• Strong computer skills

• Excellent analytical and research skills

• Excellent interpersonal skills

• Knowledge of the provider community is required

• Strong problem solving and conflict resolution skills

• Proficiency in data analysis and reporting

• Knowledge of Medi-Cal benefits and managed care regulations and compliance requirements

• Exceptional sales and marketing skills

• Knowledge of the provider and members in each community is desired

• Ability to communicate professionally by phone, in writing and in person with colleagues, providers, and other health care professionals.

• Demonstrated strong multi-tasking, organizational and time management skills

• Ability to work with a high degree of independence while seeking guidance when necessary and escalating issues to supervisor timely

• Ability to handle multiple projects simultaneously and rest priorities as needed.

Education and Experience

• Bachelor’s degree in business, Public Health or related field, or 4 years of health plan, healthcare, or public health experience.

• Requires at least three (3) years of experience in the Provider Relations Representative position or a similar role

• Desired prior experience in a managed care setting

• At least 3-4 years’ experience working with Medi-Cal/Medicaid/Medicare population or public health department