*Provider Relations Rep - El Paso, TX

Manages physician network by developing and maintaining relationships to drive business results within a specific geographic area. Provides service and education to network physicians/providers. Achieves company targets through implementation of Network Improvement plans.

Essential Functions:
  • Completes new provider orientation for all applicable product lines.
  • Conducts site visits to service providers to provides education on policies and initiatives, resolve issues, educate staff/providers on policies, collect credentialing information and review HEDIS information. Addresses RxEffect, P4P, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, etc.
  • Achieves frequency goals to establish consistent and strong relationship with provider offices.
  • Partners with local and national ancillary for appropriate vendor management and coordinates the transition of the delegated providers following a network termination.
  • Provides oversight on claims issues. Follows up with providers accordingly.
  • Monitors and supports providers using utilization reports, pharmacy profiles, ER contingencies, Frequent Flier Reports and other analytics available to improve and maintain regions.
  • Understands and explains fee-for-service and risk contracts, and provides reporting on provider and/or Service Fund performance.
  • Proactively strategies for membership growth and retention, through advanced communication to providers, as well as follow-up to gauge the response to that growth.
  • Ensures contract SLA’s are met, such as meeting with PCP’s and Specialists on a monthly, quarterly, or annual basis to address provider panels, after hour’s availability and EMR meaningful use.
  • Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.
  • Partners with finance to identify Medical Expense Initiatives to take actions necessary to successfully complete those initiatives, and assess progress on achieving financial goals.
  • Provides continual training to assigned providers on wellcare.com portal and other resources to assist with claims, authorizations, member benefits, etc.
  • Provides oversight of delegated functions, as applicable.
  • Performs special projects as assigned.
Additional Responsibilities:
  • Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.
Candidate Education:
  • Required A Bachelor's Degree in a related field
  • Required or equivalent work experience
Candidate Experience:
  • Required 1 year of experience in a Provider Relations, Account Management, Customer Service or relevant position with demonstrated ability to perform the duties of the position
  • Preferred Other Experience working in a Pharmacy, healthcare, provider or HMO/PPO environment
Candidate Skills:
  • Intermediate Demonstrated interpersonal/verbal communication skills
  • Intermediate Demonstrated written communication skills
  • Intermediate Demonstrated problem solving skills
  • Intermediate Demonstrated organizational skills
  • Intermediate Demonstrated time management and priority setting skills
  • Intermediate Demonstrated analytical skills
  • Intermediate Demonstrated customer service skills
  • Intermediate Ability to represent the company with external constituents
  • Intermediate Ability to work independently
  • Intermediate Demonstrated negotiation skills
  • Intermediate Ability to multi-task
Licenses and Certifications:
A license in one of the following is required:
    Technical Skills:
    • Required Intermediate Microsoft Excel
    • Required Intermediate Microsoft Outlook
    • Required Intermediate Microsoft Word
    Languages:
    • Preferred Other Language requirements may vary by location

    About us
    Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses exclusively on providing government-sponsored managed care services through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans to families, children, seniors and individuals with complex medical needs. WellCare is a Fortune 500 company, and in 2018, was recognized as a Fortune "World's Most Admired Company", ranking in the top five among the health insurance and managed care industry-a testament to the hard work and dedication of the company's nearly 9,000 associates who each day live WellCare's values and deliver on its mission to help its members live better, healthier lives. The company serves approximately 4.4 million members nationwide as of Dec. 31, 2017. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.