Provider Relations Rep

Fidelis Care   •  

New York, NY

Industry: Healthcare

  •  

5 - 7 years

Posted 39 days ago

Description:

As a mission-driven health plan serving all 62 counties of New York State, Fidelis Care provides quality, affordable health insurance coverage for children and adults of all ages and at all stages of life. Central to our mission is our commitment to be a health care partner, working closely with our members and providers to ensure that everyone receives the care they need, when they need it. From the beginning, Fidelis Care has worked to be part of the social fabric of local communities, impacting people’s lives with one of the most basic human rights – access to quality health care and services, close to home.

Position Summary

Assures that all provider orientations, site visits, access, and availability studies are completed within established timeframes; establishes and fosters strong positive relationships with key providers by coordinating and facilitating meetings and identifying onsite enrollment opportunities.

Responsibilities

  • Assure that all provider orientations, site visits, access and availability studies are completed within designated timeframes; assure that all providers are visited within established timeframes.
  •  Facilitate retrieval of Fidelis Care New York’s member healthcare records to ensure achievement of optimum QARR scores.
  • Conduct Access and Availability studies as needed; conduct Delegated Credentialing audits and on-site provider office assessments required for credentialing.
  • Complete credentialing and re-credentialing audits for delegated providers.
  • Investigate and resolve member complaints regarding providers to maintain member and provider satisfaction; clarify the provider's problem; determine the cause of the problem; select and explain the best solution to solve the problem and expedite correction or adjustment; follow up to ensure resolution.
  • Assist Contract Management in identification of network deficiencies and make recommendations on how to address them.
  • Establish and foster strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying onsite enrollment opportunities for Marketing.
  • Proactively identify provider needs and advise management so that action can be taken to address the needs before they are problematic for the provider.  Educate providers on the Plan’s provider incentive programs.
  • Proficiency in Microsoft Office: Excel, Word, Access; Outlook; Internet.
  •  Knowledge of various quality programs, including measures associated with QARR and HEDIS.
  •  Knowledge of various provider payment methodologies.
  •  Business Analysis Knowledge: Skilled to work in a fast paced environment. Must have strong analytical and  problem solving skills.
  •  Customer Service: Skilled to communicate with all levels of management, internal and external customers.
  •  Ability to work well as a member of a team or alone.
  •  Effective Business Communication: Skilled in communicating with technical and business constituencies in  writing effective business specifications and requirements.
  • Knowledge of claims processing.

Work Related Experience:

  • Three to five years experience working in a managed care environment serving in Provider Relations, Contract Management, or equivalent role.
  • Five to eight years related experiencerequired.

Education, License, and Certification Requirements

  • BA/BS - Bachelors Degree or equivalent preferred or Equivalent Experience.
  • Should reside in or near Suffolk County.
  • Valid Driver's license and vehicle required.

R0003513