Provider Relations Field Representative

Summary of Job

Highly visible, external-facing, field-based role, serving as the primary contact and resource for fee-for-service or value-based providers in assigned territory, with focus on government programs (Medicaid, HARP, Essential, CHP, Medicare). Under minimal direction, works directly with providers to maintain highly satisfying and functioning relationships, engaging with medical office staff, senior leaders, and physicians. Demonstrated subject matter expertise in organizational processes, policies, programs, and provider-facing tools enabling on-the-spot training and education as needed, including onboarding, management of the business relationship and performance, and issue resolution. Develop relationships that drive growth efforts proactively. Increase provider effectiveness through promotion of organizational quality, risk adjustment (condition coding accuracy), administrative cost effectiveness, and provider / member satisfaction initiatives.

Responsibilities

• Conduct a minimum of 10 on-site visits per week with designated high-touch providers to assist with provider issues, education materials, communication of EmblemHealth policies and procedures, contractual obligations, and organizational strategic initiatives.
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, quality resources, and member resources.
• Meet regularly with assigned providers to conduct training and education, such as required annual trainings, systems training, and electronic solutions (EDI, EFT, EMR, Provider Portal, Tableau reports / dashboards).
• Onboard new providers, including in-person sessions or hosting orientation webinars to educate providers on location and content of all provider-facing materials (Orientation, Provider Manual, Newsletter, Program Updates, etc.).
• Coordinate with various functions within the organization (e.g., claims, operations, enrollment, customer service, medical management, vendor management) to ensure appropriate and prompt handling / resolution of provider issues, inquiries and complaints, while balancing provider needs with organizational priorities.
• Take initiative in preventing and resolving issues between the provider and the Plan whenever possible, and independently troubleshoot problems and drive resolution.
• Initiate, coordinate and participate in problem-solving meetings between the provider and internal stakeholders as necessary.
• Support achievement of organizational strategic goals, including organic growth, performance (quality, coding accuracy, efficiency), and satisfaction.
• Deliver actionable data to providers on value-add opportunities and incentive programs.
• Support network development initiatives, including roll-out of new benefit plans, network sculpting and expansions.
• Ensure regulatory and provider network compliance requirements are met for assigned providers.

Qualifications