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Provider Relations-Networking-Contracting WellCare - Provider Relations Careers

Provider Relations Representative Job

Full Job Title: Provider Relations Representative

Job Number: 1704309

Location: Louisville, KY

Date Posted: 10-2-2017

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.


REPORTS: MANAGER, PROVIDER RELATIONS

DEPARTMENT: KENTUCKY PROVIDER RELATIONS MEDICAID STATE

POSITION LOCATION: LOUISVILLE, KY 40223

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, 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.
Candidate Education:
  • Bachelor's Degree in a related field or equivalent work experience is required
Candidate Experience:
  • 1 year of experience in a Provider Relations, Customer Service or relevant position with demonstrated ability to perform the duties of the position is required
  • Experience working in a Pharmacy, healthcare, provider or HMO/PPO environment is preferred
Candidate Skills:
  • Demonstrated interpersonal/verbal communication skills
  • Demonstrated written communication skills
  • Demonstrated problem solving skills
  • Demonstrated organizational skills
  • Demonstrated time management and priority setting skills
  • Demonstrated analytical skills
  • Demonstrated customer service skills
  • Ability to represent the company with external constituents
  • Ability to work independently
  • Demonstrated negotiation skills
  • Ability to multi-task

Technical Skills:
  • Microsoft Excel is required
  • Microsoft Outlook is required
  • Microsoft Word is required *LI-RG1

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Last Updated On: 12/9/2015