Provider Relations Representative, Sr. jobs in Carlsbad, CA

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.  

Responsible for a full range of provider relations and service interactions. Works with Director of Behavioral Health Network and  Manager of Provider Services on identifying network gaps, needs and recruitment strategies. Identifies and executes processes needed to recruit applicants. Will work with Provider Network Department staff to align recruitment efforts. Maintains and ensures the integrity of provider databases; responds to provider inquiries and provides exceptional customer service to providers, County partners, peers, staff in other departments and the general public.  The Provider Recruiter and Relations Representative may work with providers on the TERM, and/or Medi-Cal Fee-For-Service (FFS) Network(s) as well as Off Panel, Out of Network providers, Skilled Nursing Facilities, Hospitals, which includes the San Diego County Psychiatric Hospital and/or Edgemoor Hospital, as well as other medical professionals.

As part of this position, you will be required to be granted and maintain access to the County of San Diego’s electronic health record, Cerner Community Behavioral Health (CCBH ). In addition please note that if you are currently employed by the County of San Diego, further review of your application will need to occur to ensure that there is not a conflict of interest. 

If you reside near San Diego, CA, you’ll enjoy the flexibility of a hybrid-remote position* as you take on some tough challenges.

Primary Responsibilities:

• Accountable for a full range of provider relations including engagement with and development of prospective providers
• Design and implement strategies to increase the membership of providers in the network 
• Create and execute a marketing plan to build and nurture provider network  
• Identify needs in provider network, incorporating potential gaps related to composition, services, or geographical needs
• Support leadership in establishing and maintaining strong business relationships with Hospitals, Physicians, Pharmacies and Ancillary providers, and ensure the network composition includes an appropriate distribution of provider specialties
• Identify, coordinate and participate in outreach events to educate community providers on the benefit of network membership
• Establish recruiting requirements by studying organization plans and objectives and meeting with managers to discuss needs 
• Build applicant sources by researching and contacting community services, colleges, employment agencies, recruiters, media, and internet sites and  provide organization information, opportunities, and benefits while making presentations and maintaining rapport
• Attract applicants by placing job advertisements, contacting recruiters, using newsgroups or job sites
• Improve organization attractiveness by recommending new policies and practices, monitoring job offers and compensation practices, and emphasizing benefits and perks
• Update job knowledge by participating in educational opportunities, reading professional publications, maintaining personal networks, and participating in professional organizations
• Must possess the following skills-Phone and Interviewing Skills , Recruiting, , People Skills, Strong decision-making, Professionalism, Good Judgment, Organizational Skills, Project Management
• Support Diversity, Knowledge on Employment Law, Focus on Results 
• Assume additional responsibilities as assigned

Additional Responsibilities may include:

• Complete administrative processes related to the application, credentialing, contacting and re-credentialing of providers
• Review all provider applications and  documents to ensure compliance with the credentialing criteria for inclusion in the different networks 
• Track credentialing process and send provider the completed contract once process is complete 
• Run reports from provider databases to track credentialing and re-credentialing activities for a variety of provider types
• Return the signed fully executed contract to new providers in the Fee For Service and TERM networks
• Track providers’ malpractice insurance, DEA, and licensure renewals to ensure they are current/active
• Facilitate the resolution of credentialing  issues
• Coordinate and complete external and internal termination notification requirements 
• Periodically review state and federal bulletins for provider sanctions and review provider disbarment reports notifying Manager of outcome
• Attend and participate in meetings to achieve departmental and interdepartmental goals and objectives
• Triage provider related issues and escalate complex problems when necessary to Manager 
• Respond to claim issues by assessing fee schedule and contract configuration, procedure and diagnosis code questions, review modifiers and other claim form components in order to determine payment accuracy
• Organize provider files so they may be easily reviewed by staff, credentialing committee and external review bodies 
• Accurately enter and  maintain  Provider data in multiple databases to be used for directories,  payments, mailing labels and reports
• Document communication with providers in designated databases; assist in managing the integrity of databases by using contacts with providers to verify and update provider files

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. 

Required Qualifications:

• High School Diploma/GED or higher
• 2 years of experience in managed care credentialing and/or network recruitment 
• 2 years of data entry experience
• 2 years of experience working in an environment that requires coordination of benefits and working with multiple groups and resources
• Ability to travel up to 40% of the time
• Ability to work a hybrid schedule with 2 days a week in office or as needed in San Diego, CA
• Intermediate level of proficiency with Microsoft Office including Excel, Microsoft Word, Outlook

Preferred Qualifications: 

• Project management experience
• Behavioral health, provider and network experience/knowledge

Soft Skills: 

• Communication skills and ability to communicate effectively with leadership 
• Professionalism