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Provider Relations Specialist

Requisition #20354
Years of experience

2 years

Employment Type

Full-time

Required Degree

Associate Degree

Location

445 Grant Avenue, San Francisco, CA 94108

Region
Bay Area San Francisco
Application Email
Apply Now

Brief job information:

A Provider Relations specialist is responsible for working with CCHP’s provider network to address claims payment and policy inquiries. Maintain provider relationships with the health plan and its members. This critical member of the Provider Relations team will manage and resolve a portfolio of cases with medical offices and other healthcare providers.

ESSENTIAL DUTIES AND RESPONSIBILITIES

  • Under leadership of Provider Relations Management, provides customer support to providers on behalf of CCHP
  • In coordination with Provider Relations Management, acts as liaison between providers and health plan
  • Travel to provider offices and participate in provider events and work in a collaborative effort with CCHP’s Sales and Marketing Departments
  • In coordination with internal stakeholders, responds to electronic and direct inquiries from providers about policies, referrals, eligibility, claims issues, etc.
  • Supports Provider Relations Manager with daily maintenance of providers
  • Verifies and maintains accurate provider information
  • Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise
  • Participates in managed care delegated credentialing audits; conducts internal and external file audits from our medical groups and direct CCHP providers
  • Prepares and submits reports as directed or required, including but not limited to provider directories, printed and web versions, DMHC and CMS regulatory reporting
  • Identify and flag adverse information from provider application materials for conducting special follow-up investigations.
  • Manage all incoming communications from current healthcare providers via inbound phone calls and emails, researching and resolving current claims cases and communicate results
  • Make outbound calls to obtain required information for claims management or re- consideration
  • Help identify root causes of claims payment errors
  • Collaborate with other departments and/or providers in successful resolution of claims related issues
  • Generate and develop reports which include but not limited to root causes of claims payment issues
  • Ensure all compliance requirements are satisfied and that all payments are made against company practices and procedures
  • Accepts and performs other duties as assigned

QUALIFICATIONS

  • Preferably, undergraduate degree in health care administration, business or a related field and or any equivalent combination of education, industry training and directly related health care work experience
  • Understanding of managed health care delivery systems, medical terminology, operations, and HMO regulations
  • Demonstrates analytical and decision making skills
  • Ability to identify issues, recommend and implement solutions
  • Excellent verbal and written communication skills
  • Communicates effectively and collaboratively with physicians, health care providers or external/regulatory agencies
  • Flexibility, adaptability, problem solving capability, creativity, initiative, team player skills, multitasking ability, organized, and strong work ethic
  • Strong customer service skills. Ability to establish and maintain productive business relationships, manage conflict and negotiate solutions
  • Time management and organizational skills, including the ability to prioritize concurrent projects and activities, meet deadlines and work under time constraints
  • Proficiency in Word, Excel, and Access
  • Professional in manner and appearance, outstanding interpersonal skills, positive outlook, flexibility
  • Team player, energetic, dynamic, outgoing personality, and friendly
  • Knowledge of medical terminology preferred
  • Medical record and data collection skills required
  • California Driver’s license

PHYSICAL REQUIREMENTS

Able to lift up to 30 pounds

Use proper body mechanics when handling equipment

Standing, walking and moving 50% of the day.

In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require a medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.

COMPLIANCE REQUIREMENTS

Complies with CCHP Compliance Handbook including Code of Ethics and all statutes, regulations, guidelines applicable to federal and state programs. Responsibilities include, following the guidelines and reporting suspected violations of any statute, regulations, agreements or guidelines applicable to all healthcare programs.

Base Pay Scale: Starting at $24.76 – $37.11 per hour
The salary of the finalist selected for this role will be set based on a variety of factors, including but not limited to, internal equity, experience, education, specialty and training. This pay scale is not a promise of a particular wage.