Provider Services Representative

Kinetic Personnel Group is recruiting for a Provider Services Representative – Hospital Relations for a $5-billion/year public Health Plan. This Provider Services Representative is responsible for developing and maintaining strong and consistent relationships with Health Plan’s hospital and ancillary Providers. Routinely communicate organizational policies, procedures and processes, regulatory updates. Anticipate and respond to Provider educational needs and conduct ongoing training. Integral to the implementation of improvement plans with, hospitals and ancillary providers in order to meet Health Plan’s quality metrics, service goals and compliance standards.

This position is on a hybrid schedule (2 days remote, 3 office). This will begin as a temporary position with the possibility of converting to a permanent job after 6 months for the right candidate. Pay rate can go up if converted to permanent position, does include excellent pension (CalPERS), ~10% yearly bonus, 6% contribution 453b and excellent government benefits and Holiday/PTO schedule. This public health plan has been recognized as one of the best healthcare employers in the nation.

Job Duties:

• Conduct Provider orientation, continuous training and education to Providers and other stakeholders. Maintain accurate and timely log of Provider visits in compliance with NCQA standards, and DHCS and CMS regulatory requirements.

• Act as a Provider Advocate and liaison between Providers and Health Plan departments in resolving Member, Provider and other stakeholder issues and concerns.

• As assigned, visit Health Plan Providers on a periodic basis, focusing visits strategically under the direction of the Hospital Relations leadership team, in alignment with Health Plan’s quality initiatives and strategic priorities.

• Monitor Provider needs through utilization and other available reports, quality data and cases. Support Providers through training and education to improve performance and satisfaction, close care gaps. and improve access to care.

• Lead investigation and resolution of Provider grievances and health plan-related queries.

• Promote Providers’ electronic submission capabilities including the timely and complete submission of encounter data, claims and utilization data related to Health Plan’s quality metrics-.

• Communicate with Provider staff regarding pertinent issues, quality initiatives plan changes and facilitate Member and Provider case resolution.

• Maintain a strong partnership with the appropriate Health Plan departments to ensure constant, timely internal communication and coordination to support - Providers in their day-to-day operations.

• Attend internal meetings and participate in external Provider meetings and focus groups as appropriate.

• Assist Providers with interpreting Health Plan manuals and reports, including eligibility, capitation, claims data, and quality information.

• Communicate changes regarding Provider information to ensure timely update of systems and directories.

• Coordinate with appropriate departments to address Provider inquiries concerning rate/service changes and claims disputes.

• Assist with the development of the Provider Policy and Procedure Manual as requested.

• Assist with the development of written communication to the Provider network as requested.

• Assist with Joint Operations Meetings (JOMs) as scheduled and as assigned.

• As applicable, review and verify compliance of the appropriate networks, identifying gaps and requesting Provider response and submission of appropriate credentialing and related information to close network gaps and meet regulatory requirements.

• Review and verify Provider directory information and lead investigation and resolution of reported Provider directory inaccuracies.

Requirements:

• Three (3) or more experience with customer service. One (1) year of experience including Hospital, Managed Care, Medical Group, IPA and HMO. Experience with managed care.

• Bachelor’s degree from an accredited institution required.

• Working knowledge of Medical Group IPA and HMO operations. Working knowledge of hospital and ancillary provider operations preferred.

• Strong organizational skills. Excellent written and verbal communication and interpersonal skills. Microcomputer Applications (Microsoft Word and Excel, Access Preferred) for us