Regulatory Relations Specialist jobs in Miami, FL

Summary:

The Provider Relations Specialist is responsible for developing, maintaining, and servicing a high quality, marketable and satisfied provider network within an assigned geographic area. In addition, the Provider Relations Specialist will be focused on and responsible for working closely with their assigned network of providers on improving overall performance on key performing indicators, including but limited to, reducing cost, revenue, quality, etc.

Essential Duties and Responsibilities:

· Educate providers and ensure they have the tools they need to meet Quality, Risk adjustment, growth (as appropriate) and Total Medicare Cost goals per business development plans.

· Is accountable for overall performance, quality, and profitability for their assigned groups.

· Ensure Providers have in depth understanding of contractual obligations, program incentives and patient care best practices.

· Ensure the overall strategic plan incorporates interventions with case management or any other departments.

· Conduct new provider orientations and ongoing education to providers and their staffs on healthcare delivery products, health plan partnerships, processes and patient plans.

· Maintain open communication with providers to include solutions for resolution and closure on health plan issues related to claims, eligibility, utilization management, quality and risk adjustment programs.

· Conduct provider meetings to share and discuss economic data, troubleshoots for issue resolution, and implements an escalation process for discrepancies.

· Collaborate with provider groups to develop, execute and monitor performance and patient outcomes improvement plans.

· Handle or ensure appropriate scheduling, agenda, materials, location, meals and minutes of provider meetings as needed.

· Collaborate with Health Plan’s contracting team to ensure provider data is correct and include any needed updates.

· Provide information and participate in management meetings as requested.

· Regularly meets with cross functional team to create, revise, and adjust strategy for assigned Provider Groups to meet overall performance goals.

· Is designated “primary” liaison between Practice, Genuine and Health Plan Partners/CMS. Responsible for engaging with the practice and nurturing business relationship.

· Responsible for communicating and reviewing ongoing performance against Key Performance Indicators, including but not limited to those in-scope for Genuine Rewards Program.

· Engaging with other functional teams (i.e., MRA, Quality, etc.) as needed to implement key initiatives within assigned practiced focused on addressing specific opportunities.

· Must spend minimum 80% of his/her work week visiting Providers onsite at their Practice, in line with Genuine Health’s high-touch model.

· Where appropriate, focused on engaging specialists and ancillary providers who demonstrate high quality (“high performing”), and implementing best practices and communication channels between select Providers located within reasonable distance and those deemed “high performing” specialists and/or ancillary Providers.

Knowledge, Skills and Abilities

· Exceptional interpersonal skills with ability to interface effectively both internally and externally with a wide range of people including physicians, office staff, hospital executives and other health plan staff

· Demonstrated experience with making presentations to both small and large groups. Excellent communication skills (written and verbal) and ability to communicate effectively with external and internal audience at all levels

· Ability to gather and analyze information and communicate to others

· Analytical, problem-solving, and troubleshooting skills

· Time management and organizational skills

· Ability to work well with others and work in a team environment

· Pays close attention to detail, is resourceful and highly dependable

Minimum Qualifications:

· 5 years of experience in a healthcare-related position, preferably managed care environment and/or Bachelors' Degree in a health-related field or Business Administration or equivalent combined experience

· 3 years’ experience in Provider Relations, Network Management, Contracting, Credentialing

· Must have a valid Driver’s license, clean driving record, and reliable transportation.

· Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access, and Power Point). Moderate to advanced in excel.

· Prior experience and/or knowledge of HEDIS, CMS Star Rating System, and/or Medicare Risk Adjustment is preferred.

· Prior experience and/or knowledge of CMS and Medicare Advantage payment methodologies, and Value-Based Contracting is preferred.

· Bilingual: Spanish and English.

Genuine Health Group offers a competitive compensation and benefits package that includes a 401k matching program, fully subsidized medical plans, paid holidays and much more. Base salary will be commensurate to professional experience.

Genuine Health Group is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.