Provider Relations Representative

American Health Plans manages institutional special needs plans (I-SNPs) in nursing homes in several states by sharing plan ownership with the facilities.

Our roots in managed care run deep. We owned and managed a Medicare Advantage plan with over 100,000 members across multiple product lines.

We currently own one of the oldest provider-owned I-SNPs in the country and are rapidly developing new partnerships with nursing home owners.

Today, you can find our managed care plans in 123 nursing homes, and we are rapidly developing new partnerships with nursing home owners.

POSITION SUMMARY :

The purpose of this position is to analyze assigned existing market needs, performs some standard contracting functions, educates providers and provider service entities, maintain business relationships for the Health Plan(s), reports on provider and market changes, acts as a support for other service areas for the Health Plan(s).

ESSENTIAL FUNCTIONS : To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation

• Contracting providers and essential vendors in current service areas to maintain CMS adequacy and providing necessary services in the care of the Plan members
• Insuring providers and essential vendors in current service areas meet the credentialing requirements for their appropriate service lines
• Educating providers on the Health Plan(s) functions and roles in caring for its membership
• Ongoing educational updates as prescribed by CMS and the Health Plan(s) policies
• To conduct the education presentations of the Health Plan(s) providers to insure their understanding and commitment with the Health Plan(s)
• Monitor, maintain and support provider relationships to insure network coverage in all areas
• To work with and be involved in implementation as needed
• Establish a positive work environment that encourages participation in process improvement and commitment to department / company success
• Complete corporate assignments as assigned

Required Skills :

• Must be fluent in all current provider payment methodologies including per diems, DRGs, and APCs
• Must have knowledge and familiarity with all levels of medical services and ability to rapidly develop working relationships
• Must be able to accept instructions and work independently in the completions of goals and assignments
• Must have strong negotiation, organization, presentation and time management skills
• Must be able to effectively communicate with all levels of medical staff to explain Health Plan(s) program, benefits and goals
• Must be able to work effectively in a team environment
• Excellent computer skills, including Microsoft Office Suite
• Must be self-motivated, dependable, team and goal-oriented

Required Work Experience :

• Experience in the health care field required
• Prior experience in network development / network services is preferred
• Prior experience with acute and post-acute facilities is beneficial
• Prior experience with Medicare Advantage plans is helpful

Licensing / Certification / Education Requirements :

Bachelor’s degree preferred, but not required, with emphasis in Healthcare Administration / related field or three (3) years of experience in managed care network development / network services

Other Requirements :

• Must be available to work 8 a.m. until 5 p.m. local time
• Position requires travel to network provider locations.
• Teleworking is an option if criteria are met

Required Computer Software / Equipment Used :

• Microsoft Suite including Outlook, Excel, and Word
• Standard Office Equipment
• Computer

Physical Requirements :

• Allows discretion for standing, walking, sitting
• Work is performed in a standard office environment; well-lit; comfortable temperature controlled; average conversational noise is frequent
• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions

Required Safety Expectations :

• Working safely and follow safety rules
• Report unsafe working conditions and behaviors
• Take reasonable and prudent actions to prevent others from engaging in unsafe practices

Supervisory Responsibilities :

• Does not have direct supervisory responsibilities
• Supervisor frequently determines priorities
• Occasionally needs manager’s direction due to extraordinary circumstances
30+ days ago