Central Valley Medical Group Hiring for Provider Relations Representative for Central Valley Medical Group IPA Job at Modesto, CA Full Time

Provider Relations Representative for Central Valley Medical Group IPA

This position is responsible for managing all physician recruitment and network development activities within a specific territory. This requires regular consultative contact with every contracted physician office in a designated territory to build rapport, generate new patient membership, maintain existing patient membership, and service existing contracted physician office with a heavy emphasis on practice education and office in-service. In addition, this role will ensure practice are compliance with regulatory requirements when it comes to patient access and promoting annual wellness visits performance, plus improving network performance in its quality and clinical measures.

Essential Responsibilities:

• Develop, manage, and increase patient membership, physician network, promote company brand, and service physician offices in a specific territory which requires face to face consultative contact with every physician via in-person or virtually.
• Plan, organize, and implement effective strategies using all company programs, tools, and initiatives to increase market share in designated territory.
• Document all physician office interactions and other pertinent information in applicable databases to provide an accurate record of physician encounter history. All field staff must document activity for current day by 9 am following business day via web-based CRM system.
• Address and resolve provider claims, capitation, authorization, referral, and contract issues in a timely matter, plus identifying root cause and making the necessary operational changes to mitigate issue.
• Conduct 4-6 office visits per week which is performed in-person or virtually.
• Conduct quarterly office manager and staff meetings to educate the physician network on policy and procedural changes, new protocols, changes to the network and/or health plan changes, and regulatory updates.
• Provider Relations Representative is required to work in conjunction with the ACO Network Manager and Provider Relations Specialist to ensure day-to-day operations are functioning at a high level and providing satisfaction to our network of physicians and their staff.
• Maintain professional and consistent communication with the ACO unit, MSO staff, Executive leadership, and/or the Board of Directors and perform activities as directed.
• Respond in a professional fashion to physician office concerns, executing follow up actions to ensure physician office issues/opportunities are communicated to the appropriate departments.
• Maintain accountability for adherence to company and divisional organization policies and procedures.
• Participate in special projects and perform other duties as required.
• Educate offices on their current performance on key performance indicators (KPIs) which includes but not limited to Annual Wellness Visits, Quality Performance, Clinical Measures, Risk Adjustment Score, Patient Satisfaction, and identify low performing PCPs and develop action plans for specific metrics needing improvement.

Qualifications:

• General knowledge of Medicare Advantage, traditional Medicare, Commercial HMO, PPO and ACO products
• Knowledge of and understand contract language and DOFR risk
• Knowledge of and understand medical claims processing and adjudication in a managed care environment
• Knowledge of and understand authorization and referral processing in a managed care environment
• Knowledge of and understand the provider credentialing process
• Strong technical skills and highly proficient in Excel, PowerPoint, and Word
• Ability to communicate with others clearly, tactfully, and professionally
• Strong and effective writing and oral communication skills: ability to write clearly and concisely and at a professional level
• Team leadership skills to train and assist less experienced personnel
• Ability to multi-task
• Ability to work independently and as part of a team
• Ability to assess clients’ business and identify improvement opportunities
• Dependable and able to hold self accountable and to a high standard

Essential duties and responsibilities:

• Provider and clinic staff education and training via in-person or virtually
• Educate offices on contract compliance requirements
• Dissemination of numerous reports to Physician offices
• Update physician profiles and data in the System
• Communication & interaction with health plan representatives, agents/brokers, stakeholders, and executive leadership
• Collection of materials, documents, and information Such as IHAs, AWEs, credentialing applications, contracts, and other items as needed

Job Types: Full-time, Part-time

Pay: $22.00 – $28.00 per hour

Schedule:

• Monday to Friday

Ability to commute/relocate:

• Modesto, CA: Reliably commute or planning to relocate before starting work (Preferred)

Experience:

• Provider Relations Representative: 1 year (Required)
• Customer service: 1 year (Required)

Work Location: One location