Provider Relations Representative, Sr. jobs in Monterey, CA

ABOUT US

Join us in making a career in Independent Living Systems, an industry leader in managing home and community-based programs for over 20 years. Independent Living Systems, LLC and its subsidiaries offer a comprehensive range of clinical and third-party administrative services to managed care organizations and providers that serve high-cost, complex member populations in the Medicare, Medicaid, and Dual-Eligible Market. ILS provides tailored integrated solutions aimed at improving health outcomes while rebalancing costs, addressing social determinants of health and connecting members with community-based resources.

POSITION SUMMARY

The Provider Relations Account Executive is responsible for developing, maintaining and servicing a high quality, marketable and satisfied provider network within an assigned geographic area. The Provider Relations Account Executive targets providers in their assigned geographic area and establishes relationships that optimize contract value to ILS and the provider to drive growth.  This position is expected to build and sustain strong working relationships with cross functional departments and assigned Long Term Care and Health Care Providers. The Provider Relations Account Executive helps assigned Providers operate successfully within our healthcare delivery model by providing strategic education on the special needs of the enrollees, comprehensive understanding of the contract and the PSN plans quality initiatives.

ESSENTIAL FUNCTIONS

1. Works with ILS leadership to develop targeted plans to grow and maintain solid relationships with current providers; and establish and build relationships with newly aligned provider to drive plan performance and enrollment.
2. Educating the providers to ensure they understand the contract and the Medicaid and Medicare initiatives regarding this population and the contract requirements.
3. Educating the providers to the mandated best practices for their provider type and identified quality measures.
4. Coordinates with other ILS internal departments to resolve questions or issues regarding prior authorizations, claims submission or payment issues.
5. Perform and participate in field visits including provider contracting, education and training, and networking meetings and events. 
6. Develop programs with community providers which generate recognition and position ILS and its provider network as the preferred provider network for participation and referral.
7. Collaborates with the Provider Training Specialist to ensure new provider orientations and ongoing education to providers and their staffs regarding claims, payments, eligibility, utilization management or any other questions impacting provider performance.
8. Conducts provider meetings to share and discuss issues of concern, troubleshoots for issue resolution, and implements an escalation process for discrepancies.
9. Collaborates with Credentialing Department to ensure provider data is correct and include any needed updates.
10. Assists providers to obtain and complete Provider Change Forms as needed.
11. Provides information and participate in management meetings as requested.
12. Regularly meets with ILS leadership to create, revise and adjust strategy for assigned Provider Groups to meet overall performance goals.
13. Other duties as assigned.

EDUCATION AND EXPERIENCE

• BA or BS degree or a minimum of five years’ experience as a Provider Relations Account Executive with a Health Plan.
• Bi-lingual in Spanish and English
• Ability to Lead team(s), motivate others and engage others at all levels.
• Formal presentation skills required.
• Ability to analyze complete concepts including Provider Reimbursement methodologies, reports and provide resolution within required timeframes.
• Microsoft Office applications.
• Effective Highly organized and self-motivated.
• Capable of working independently.
• Ability to interact with people of all ages and cultural backgrounds.
• Sound, current computer and small office management skills. Excellent Excel skills.

 REQUIRED SKILLS

• Verbal Communication.
• Written Communication.
• Teamwork.
• Organization and Planning.
• Problem Solving.
• Ethical Conduct.
• Strategic-Critical Thinking. 
• Leadership.
• Decision Making. 
• Financial Management. 
• Communications Proficiency. 
• Presentation Skills.

EEO STATEMENT 

In compliance with the Drug-Free Workplace Act of 1988, Independent Living Systems has a longstanding commitment to provide a safe, quality-oriented, and productive work environment. Alcohol and drug abuse pose a threat to the health and safety of ILS employees and to the security of the company's equipment and facilities. For these reasons, ILS is committed to the elimination of drug and alcohol use and abuse in the workplace. Independent Living Systems, LLC, and its subsidiaries, including FCC, provides equal employment opportunity to all individuals regardless of their race, color, creed, religion, gender, age, sexual orientation, national origin, disability, veteran status, disability, ancestry, or any other characteristic protected by state, federal, or local law. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.