Provider Relations Representative, Insurance Services

The Provider Relations Representative is responsible for addressing provider issues applying resolutions and responding to inquiries in an accurate and timely manner for both participating and non-participating providers. The Provider Relations Representative trains new and existing providers in accordance to Community Care Health (CCH) policies and procedures and completes provider on-site audits. Additionally this position delivers provider relations support to internal departments including but not limited to Contracting/Network Management Quality Compliance and Medical Management. The provider representative also leads small projects for the department.

Key Responsibilities:

• Field Liaison:Acting as the go-between for the health plan and providers.

• Field Presence:Out of the office regularlyinterfacing directly withthe provider community.

• Education:Meeting with office staff to teach them how to use the portal check eligibility and understand prior authorization policies.

• Problem Resolution:Triaging provider issues (claims authorizations eligibility) and following through with internal departments (Claims UM) until resolved.

• Data Integrity:Working with Provider Network Ops to audit and update the provider directory.

On-site (Base office at Shaw) when not traveling to providers offices. This position will have heavy field travel to provider offices.

Education

• High School Diploma High School Equivalency (HSE) or Completion of a CHS Approved Individualized Education Plan (IEP) Certificate required
• Bachelors Degree in Business or Healthcare Administration required
• Equivalent combination of education and experience may be substituted for the Bachelors Degree requirement

Experience

• 2 years of experience in managed care physician office or health plan environments required
• Health Plan experienceis highly preferred to navigate internal issue resolution.
• Local candidatesare a major plus (those with existing local provider relationships).
• Experience preferred for core systems:QNXT (will train) Word and basic Excel (for tracking visits).
• High-level presentation skills patience and strong listening/articulation abilities preferred.