Provider Relations Representative – Partnership HealthPlan of California – Fairfield, CA

Overview:

To establish and maintain excellent relationships with the provider network in a specific geographic region, including healthcare practitioners, office staff, and administrators. Works closely to identify and resolve complex issues, provides education and staff training. Provides service and education via onsite visits and telephone. Assists providers with understanding Partnership HealthPlan of California’s policies and procedures and assists with resolving issues that arise.

Responsibilities:

• Maintains regular schedule of provider office visits to ensure open lines of communication, answers questions, distributes information, and documents and follows-up on questions or concerns. Ensures each visit includes a well-documented Rep Visit Sheet.
• Investigates and responds to provider concerns. Serves as neutral liaison between providers and PHC departments in responding to questions and resolving issues. Assists with research and disposition of provider appeals and grievances.
• Trains provider offices via onsite visits and by telephone regarding PHC policies, procedures, and available resources.
• Creates educational materials and formal presentations.
• Conducts provider orientations and ongoing educational training sessions. Assists with meeting coordination to ensure agendas are distributed timely and materials and other required arrangements are prepared.
• Educates providers on the use of PHC provider information forms. Follows up with providers on incomplete forms to obtain required information.
• Resolve complex authorization or claims issues. Identify potential system issues, collaborate with affected departments to ensure resolution.
• Conducts monthly, quarterly, annual and ad hoc provider surveys.
• Creates Corrective Action Plans (CAPS) for provider sites that did not meet standards. Monitors compliance with CAP.
• Uses databases and tracking systems to document and retrieve information and run reports.
• Composes correspondence, conducts research, and prepares reports.
• Coordinates, attends, and participates in various meetings both on and off-site as assigned.
• May be required to report on major points, resolved and pending action items.
• Required to work with minimal supervision.
• Other duties as assigned.

Qualifications:

Additional Comments:

• Must live in Lake County and have knowledge of the county health system

All HealthPlan employees are expected to:

• Provide the highest possible level of service to clients;
• Promote teamwork and cooperative effort among employees;
• Maintain safe practices; and
• Abide by the HealthPlan’s policies and procedures, as they may from time to time be updated.

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.