Provider Relations Specialist

 

Position Title:



  PROVIDER RELATIONS SPECIALIST

Department/Unit:

Provider Relations

Reports to:

Manager, Regulatory Compliance and Provider Relations

Responsibilities:

% Weight

1.

Helpful

25%

 

a.

Ensure timely sharing of required information with appropriate individuals, both internal and external, including the status of assigned projects and duties.

 

b.

Respond to complex provider inquiries and disputes regarding contractual issues and adherence to the Participating Provider Manual.

 

c.

Assist, as needed, with Quality Service Reviews (QSR) of participating provider offices as outlined in the Quality Management Program (QMP) and QSR Manual.    

 

d.

Assist the Team Leader and Manager with other duties and projects as assigned.

 

e.

Assist internal and external customers by effectively demonstrating the company’s established service standards.

 

f.

Willingness to adapt, with positive attitude, to changes in processes, responsibilities, and assignments.  

 



2.

Accurate

25%

 

a.

Ensure accurate provider information in all provider databases.

 

b.

Preparation and analysis of provider data and reports for management, QMC, and the Board of Directors. 

 

c.

Prepare, review, and submit required reports and correspondence with complete accuracy and attention to detail.

 

d.

As needed, enter provider data with no or minimum keying errors.

 

e.

Strictly adhere to established policies and procedures to guarantee consistent outcomes.

 

f.

Clearly understand all duties and tasks to ensure complete, high-quality results.

 

3.

 

Ownership

 

25%

 

a.

Maintain relationships with participating and prospective providers, including delegated groups.

 

b.

Assist with the negotiation of contract provisions and contractual rates. 

 

c.

Monitor and update data on all delegated credentialing groups as needed.

 

d.

Demonstrates reliable and dependable attendance.

 

e.

Demonstrates ability to follow procedures, standards, and rules.

 

f.

Recognize opportunities for improvement; communicate opportunities to appropriate person(s).

 

g.

Take responsibility for ensuring a safe and professional work environment.

 

h.

Uphold the confidentiality of appropriate information, including but not limited to protected health information.

 

4.

 

Efficient

 

25%

 

a.

Effectively use all forms and materials to ensure the timely collection, input, and implementation of required data.

 

b.

Assist with the development and improvement of QM and QI forms and materials to meet or exceed regulatory and industry standards.

 

c.

Assist internal departments on all provider issues regarding network participation and panel access issues.

 

d.

Assist with the development, implementation, and improvement of processes and procedures.

 

e.

Assist with departmental and company staff training as needed.

 

f.

Perform and complete tasks within prescribed deadlines with consistent quality results.

 

 



Knowledge and Skill Requirements:

1.

Able to provide quality customer service

2.

Able to handle difficult and/or irate customers on the telephone

3.

Able to keep confidential information

4.

Strong research and analytical skills

5.

Above-average verbal and written communication skills

6.

Above-average proficiency in MS Word, Excel, and PowerPoint; knowledge of database applications a plus

7.

Detail-oriented with excellent organizational skills

8.

Able to multi-task and manage projects

9.

Able to perform all duties and responsibilities with minimal supervision

Education Requirements:

College degree or equivalent experience that equates to a minimum of five years in an office environment, preferably in the health care industry.

 

Physical Demands and Work Environment:

May be required to lift and carry no more than twenty (20) pounds when moving office supplies and/or equipment

May be required to do office errands (e.g. posting mail)

May be required to reach, stoop, bend, kneel, crouch, and stretch in the course of performing tasks.

The position requires long periods of sitting and working at a computer.

Occasional travel may be requested to assist with Quality Service Reviews of provider offices.