Develops and promotes a positive perception of assigned business unit by cultivating a customer-oriented, collegial relationship with providers and clients. Specifically, charged with conducting effective, clinically-substantive provider and client education and training programs for new network participants and new client implementations, as well as when provider performance issues warrant remedial focus. Leads in responding to and resolving provider issues; facilitates problem-solving with other internal operations stakeholders and client provider relations staff to achieve fair and timely resolution and positive outcomes with providers. Additionally, requires being proactive in communicating with high-impact providers in each market to ensure that the highest provider satisfaction levels are achieved and client appreciation is gained as a result.
- Provides orientation, training, education meetings, presentations, and focus groups to improve mutual understanding and enhance working partnerships with providers.
- Oversees the high denial outreach/non-responder/high appeals initiative in all markets, initiating clinical education meetings with physicians.
- Establishes and maintains optimal communication channels with client provider relations and account management, promoting business unit's ability to rapidly resolve provider issues.
- Collaborates with network management, corporate management, account management, operations, QI and other internal stakeholders through internal meetings and needs analysis to develop and implement proactive provider relations improvement strategies.
- Provides summary and problem specific feedback information, analysis, action recommendations to service center senior management and relevant functional units regarding provider problems, issues, and general concerns impacting working relationships and company image.
- Manages provider relation`s department day to day activities and may manage staff.
- Directs, monitors, trends, routine and long-standing provider complaints, claims, contracting, credentialing and other problems requiring regional service center follow-up and resolution.
- Facilitates immediate resolution of red-flag provider issues that are client, community, legal, or contractual threats with internal personnel as needed.
- Routinely monitors provider performance to target and perform remedial training sessions based upon area of need (e.g., authorization processes, claims submissions, etc.)
- Performs administrative site visits for potential high volume providers on ad-hoc basis.
Other Job Requirements
7+ years in a Provider Relations role for a managed care plan., Solid knowledge of health plan operations required. Depending on assigned business unit, knowledge or experience in management of medical drug benefits, specialty pharmacy, pharmacy benefits management (PBM), behavioral health, or radiology may be required.