Provider Relations Representative - Managed Long Term Care

WellCare Health Plans Inc. West Palm Beach, FL
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: Sr. Manager, Provider Relations

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, etc.

* 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 strategizes for membership growth and retention, through advanced communication to providers, as well as follow-up to gauge the response to that growth.

* 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 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 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 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

Technical Skills:

* Required intermediate Microsoft Excel

* Required intermediate Microsoft Outlook

* Required intermediate Microsoft Word


* Preferred Bilingual English/Spanish