Provider Relations Rep-Charlotte

Manages provider Network performance for assigned territory with an account management approach. Achieves market performance targets through the implementation and execution of Network transformation strategies in order to improve overall Network performance.

Department: Provider Relations

Location: Charlotte, NC

Reports To: Director Provider Relations

Essential Functions:

  • Owns and manages contractual relationship and performance of assigned in-network provider groups. Serves as primary point of contact for assigned providers.
  • Evaluates provider performance via Enterprise Provider Dashboard and develops performance action plans.
  • Completes new provider orientation for all applicable product lines to educate on policies and initiatives, resolve issues, and educate staff/providers. In addition, drives adoption and utilization of RxEffect, P4Q, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, etc.
  • Establishes consistent and strong relationships with provider groups utilizing an account management approach.
  • Establishes and leads cross-functional communication with internal departments.
  • Collaborates with internal cross-functional team to support provider performance and resolve barriers and challenges.
  • Drives improvement of provider performance by analyzing, interpreting, communicating utilization and quality metrics. Responsible for developing and executing performance improvement plans.
  • Understand and explains fee-for-service reimbursement to providers and management.
  • Understands fee-for-service contractual arrangement and works with internal support team to resolve provider contractual inquiries.
  • Plans, prepares and executes effective group meetings/discussion with proper objectives and expected outcomes with internal and external customers.
  • Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.
  • Provides continual training to assigned providers on 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
    • Preferred Other Language requirements may vary by location

    About us
    Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at 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.