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Essential duties and responsibilities include the following:
The Provider Relations Specialist is responsible for developing, maintaining and servicing high quality, marketable and satisfied provider network within an assigned geographic area. This position is expected to build and sustain strong working relationships with cross functional departments, and assigned Providers. The Provider Relations Specialist helps assigned Providers operate successfully within our healthcare delivery model by providing strategic education on the special needs of the enrollees, comprehensive understanding of the contract and the PSN plans quality initiatives.
Key responsibilities include the following:
Educating the providers to ensure they understand the contract and the Medicaid initiatives regarding this population and the contract requirements of the PSN.
Educating the providers to the mandated best practices for their provider type and the quality measures of the PSN.
Coordinates with other PSN internal departments to resolve questions or issues regarding prior authorizations, claims submission or payment issues.
Conducts new provider orientations and ongoing education to providers and their staffs regarding claims, payments, eligibility, utilization management or any other questions impacting provider performance.
Conducts provider meetings to share and discuss issues of concern, troubleshoots for issue resolution, and implements an escalation process for discrepancies.
Handles or ensures appropriate scheduling, agenda, materials, location, of provider meetings as needed.
Collaborates with Credentialing Department to ensure provider data is correct and include any needed updates.
Assists providers to obtain and complete Provider Change Forms as needed.
Provides information and participate in management meetings as requested.
Regularly meets with other Provider Specialists to create, revise and adjust strategy for assigned Provider Groups to meet overall performance goals.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Verbal Communication Excellent verbal communication skills with the ability to clearly present information orally and/or influence others through oral presentation.
Written Communication Excellent written communication skills with the ability to effectively write and extract information from written material.
Team Work Ability to work with people and effectively motivate others to achieve intended goals and objectives.
Organization and Planning- Ability to prioritize, organize tasks and develop the necessary action plans to accomplish specific goals, within the required timeframes/deadlines.
Leadership Ability to influence the actions and opinions of others in a desired action; to exhibit good sound judgment in leading others to profitable and rewarding objectives.
Decision Making and Problem Solving: Ability to identify a problem and implement interventions and solutions while exhibiting good sound judgment in the process; ability to take a systematic approach to decision making by identifying a problem or deficiency, examining the cause or barriers, and implementing interventions and improvement strategies.
Travel Ability to travel within Florida and outside of Florida, as necessary to visit providers, attend meetings and trainings.
EDUCATION and/or EXPERIENCE:
BA or BS degree or a minimum of five years experience as a Provider Relation Specialist with a Health Plan.
Bi- lingual Spanish English
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 essential functions.
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.