Sr. Provider Operations Representative

Description

Position Summary:

The Provider Operations Senior Representative develops long-term relationships with physicians and providers in order to support and improve financial and quality performance within the contracted working relationship with the health plan. The Senior Provider Engagement Professional work assignments involve moderately complex to complex issues where the analysis of situations or data requires an in-depth evaluation of variable factors.
 

Essential Duties and Responsibilities:

1. Represents the scope of health plan/provider relationship across such areas as financial performance, incentive programs, quality and clinical management, population health, data sharing, connectivity, documentation, and coding, HEDIS performance, operational improvements, and other areas as they relate to provider performance, member experience, market growth, provider experience and operational excellence. Seeks to identify providers that demonstrate strong understanding of population health and partners with them to achieve a value-based contract.
2. Influences department’s strategy based on feedback collected during provider engagement sessions.
3. Makes decisions on moderately complex to complex issues regarding technical approach for project components, and work is performed without direction.
4. Exercises considerable latitude in determining objectives and approaches to assignments.
5. Support Network Quality Initiatives by participating in process improvements to support quality outcomes. Educate the physicians and office staff about Clinical initiatives and quality programs.
6. Familiar with various contracting strategies and payment methodologies.
7. Provider meetings are primarily held face to face, in order to maximize the exchange of information and ideas specific to the particular physician circumstance.
8. Assists new and existing providers with credentialing requirements and procedures for contracted health care providers. 
9. Provides tactical operations support to assigned groups including data integrity, communications, and relationship management.
10. Prepares and delivers presentation with providers, provider staff, and/or physician leadership during monthly operational meetings.
11. Performs root cause analyses and resolutions related to provider concerns, grievances, claims and care delivery.
12. Research issues that may impact future provider negotiations or jeopardize network retention.
13. Documents site visits and results for NCQA purposes.
14. Assists with ensuring that providers are compliant with NCQA requirements regarding availability and access to standards and evaluates the standards to ensure they address the requirements outlined by NCQA.
15. Reviews claims reports for denials and works with providers to improve claim submissions and provider data updates to ensure accurate claim adjudication.
16. Educates providers regarding policies and procedures related to referrals and claim submissions, website usage, EDI solutions and related topics.
17. Performs other duties as assigned.

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.

Skills and Abilities:

• Interpersonal Effectiveness: Understands oneself, effectively manages emotions, listens, and communicates with respect, and builds trusting relationships.
• Executes for results: Effectively leverages resources to create exceptional outcomes, embraces change, and constructively resolves barriers and constraints.
• Accountability: Meets established expectations and takes responsibility for achieving results; encourages others to do the same.
• Builds trust: Consistently models and inspires high levels of integrity, lives up to commitments, and takes responsibility for the impact of one’s actions.
• Detail oriented.
• Critical thinking skills.
• Organizational skills.
• Interpersonal skills.

Work Schedule:

As a continued effort to provide a safe and productive work environment, Community Care Plan is currently following a hybrid work schedule. Staff are able to work from home 3 days a week and will report to the office 2 days a week. *****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.

Qualifications

• Bachelor’s degree or equivalent experience required.
• 5-7 years managed care experience or administrative support experience in an IPA, PHO or MCO setting.
• Strong analytical background with proficiency in programs such as Microsoft Excel.