Provider Relations Representative (52758)

Who You Are

• Responsible for quality assurance of the provider data integrity, for responses to provider inquiries with research and resolution, and to insure proper categorization of provider directory.

Essential Job Functions

• Assists in maintaining accurate Provider/Vendor records and Provider Directory
• Develop and evaluate the provider network to ensure appropriate access and availability for Health Plan membership
• Create and verify Provider Data integrity with on-going monitoring and responds to daily inquiries in a timely manner
• Educate and assist providers to maximize data integrity and provider experience
• Cultivates and maintains collaborative internal and external relationships to maintain and improve positive interpersonal relations and execute network strategies
• Responds timely to provider nominations by providing guidance and insight to leadership based on network need
• Actively participates and assists in meeting CMS guidelines and NCQA accreditation standards
• Assists in the on-boarding of new providers. This may include training and education to providers to ensure success in the program.
• Resolves Provider Inquiries via Provider Relations email, CRMs, Joint Operating Committees and surveys in a timely manner.
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned

Education and Experience

• High school diploma or equivalent is required
• Bachelor's degree preferred
• At least two years of related experience with a payer or provider organization with responsibility for provider relations, provider credentialing, and/or provider information management required

Knowledge, Skills and Abilities

• Computer Proficiency: Demonstrated proficiency in the use of personal computer applications; specific skills to include Microsoft Word, Outlook, Excel v-lookup, and ability to build and compare files using NPPES data and provider taxonomy
• Interpersonal Skills: Ability to quickly develop rapport and work effectively and professionally with all levels of personnel
• Problem-Solving Skills: Ability to investigate/research problems and issues and to recommend associated corrective actions
• Discretion: Ability to manage sensitive or confidential information in a professional and discreet manner

Work Environment

Current work environment is remote, however, some state exclusions apply. Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.

Supervisory Responsibility

This position has no supervisory responsibilities.

Other Duties

This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.