Provider Relations Representative, Sr. jobs in Oceanside, CA

Position Title: Provider Relations Representative

Department: Network Management

Level: Non-Supervisory

Reports To: Director of Network Management

Position's Access to Private Health Information (PHI): Requires access to PHI, including “read only” access to eligibility, claims, and authorizations. “Write” access to member notes and provider notes.

Job Classification: Non-Exempt

Job Type: Full-Time

Pay Rate: $27.89 - $35.27/hr. Salary is based on qualifications and experience.

Position Summary:

Primary liaison between the client and MSO for the delivery of Managed Care Administrative Services. Responsible for concise and complete explanations of all phases of services from each MSO Department to the assigned IPA groups and resolving issues between them.

Essential Job Functions:

• Coordinates and co-chairs all client board and regional meetings within assigned territory. Maintains official copies of minutes, agendas and credentialing signatures at the MSO’s office. Sends announcements regarding scheduled meetings, makes phone calls to verify attendance (quorum), orders refreshments and sets up/breaks down the meetings. Prepares, or directs the preparation of, agendas, handouts and meeting minutes. Represents management at all meetings with clients in an appropriate and professional manner.
• Serves as a resource for internal referrals on provider issues. Supports the Client Services Department in resolving provider issues and responds to training needs identified by other MSO departments such as Claims and Medical Management. Interfaces with Health Plan staff as required. Effectively problem solves issues as identified; documents all contact with providers/office staff in the provider’s file. Monitors client needs to evaluate satisfaction levels, and identifies trends and areas requiring improvement.
• Manages the interface between providers, the MSO and the health plans. Remains accessible to providers and their office staff. Leaves specific instructions about how to be reached within and outside the office. Utilizes email and the cell phone to maintain productivity within and outside the office. Schedules regular visits with physician offices to provide education, training and customer service. Establishes and maintains strong, productive relationships with office staff by providing superior customer service and effectively solving issues. Stays current with activities in the market by developing an open rapport with the offices. Represents management at all meetings with clients in an appropriate and professional manner.
• Recruits providers in designated geographic areas, negotiates provider contracts within specified guidelines and assists the Director of Network Management in all phases of network negotiations and contracting. Investigates interested providers for consideration by the regional committee. Notifies health plans and appropriate internal departments of provider contract and status changes. Functions as a messenger between plans and IPA clients, as applicable, during contracting functions.
• Develops provider manuals, provider directories, provider communications, and other related materials; and facilitates the distribution of such information.
• Internet portal user set-up, training, documentation, communication and troubleshooting with vendors as necessary.
• Completes other duties as requested and assigned.

Position Qualifications and Requirements:

Experience/Specialized Skills:

• Proven experience in managed care operations, with a minimum of three years experience in managed care.
• Knowledge of CPT, ICD-9 Codes.
• Exposure to contract language, rates, and coverage definitions.
• Must have the ability to communicate in a professional manner, have problem solving skills and work independently.
• Excellent organizational and interpersonal skills.
• Ability to work effectively with a wide variety of people at all levels.
• Experience training individuals on managed care policies and procedures in small or large groups. Presentation skills.
• Experience organizing meetings and taking minutes.
• Ability to conduct on-line meetings and conference calls.
• Must have reliable transportation, valid California Driver’s License and proof of insurance.
• Computer literacy, including competence with various word processing and managed care programs. Microsoft Office familiarity required.

Education/Course(s)/Training:

• Associates Degree required with a combination of related experience and training.
• Bachelor’s Degree preferred.

Licensure/Certification: N/A

Location: Mira Mesa, San Diego

Date Posted: 04.02.2024

To apply for this position, complete the employment application following the link below and submit it to jobs@scpmcs.org

Job Type: Full-time

Pay: $27.89 - $35.27 per hour

Expected hours: 40 per week

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Tuition reimbursement
• Vision insurance

Schedule:

• 10 hour shift

Application Question(s):

• What are your Salary Expectations?

Education:

• Associate (Required)

Experience:

• Managed Care Operations: 3 years (Required)
• CPT and ICD Coding: 1 year (Required)

License/Certification:

• Driver's License (Required)

Ability to Commute:

• San Diego, CA 92121 (Required)

Ability to Relocate:

• San Diego, CA 92121: Relocate before starting work (Required)

Willingness to travel:

• 50% (Required)

Work Location: Hybrid remote in San Diego, CA 92121