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.
DEPARTMENT: Provider Relations
REPORTS TO: Manager, Provider Relations
- 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, et al.
- 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.
- Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.
- 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.
- A Bachelor's Degree in a related field required.
- 1 year of experience in a Provider Relations, Customer Service or relevant position with demonstrated ability to perform the duties of the position required.
- Experience working in a Pharmacy, healthcare, provider or HMO/PPO environment preferred.
- 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.
- Intermediate proficiency in Microsoft Outlook, Word, and Excel.