Provider Relations Representative - PCP

About the role

The Provider Relations Representative supports provider onboarding, training, education, and inquiry/issue support and resolution for the Humana Healthy Horizons in Virginia Medicaid Plan. This role develops and grows positive, long-term relationships with physicians, providers, and healthcare systems.

Responsibilities

• Serve as primary relationship manager with assigned providers to ensure positive provider experience with Humana Healthy Horizons and promote network retention
• Meet regularly, both in-person and virtually, with assigned providers to conduct training and education, including, but not limited to, required annual trainings, periodic updates to and/or reviews of Humana policies and procedures, and Humana systems training and updates
• Support newly assigned providers with onboarding, including hosting orientation sessions
• Respond to assigned provider inquiries and support prompt issue resolution, including, where necessary, collaboration with appropriate enterprise business teams (e.g., claims payment, prior authorizations & referrals)
• Work with internal resources and systems (e.g., claims, reimbursement, provider enrollment) to provide the Exceptional Experience in all provider interactions
• Create provider trainings based on provider feedback, trends in claims or process changes
• Educate provider on location and content of all provider facing materials (Orientation, Provider Manual, Newsletter, Program Updates, Etc.)
• Convene regular meetings with providers, including organizing agendas, materials, meeting minutes, other team members (clinical, provider engagement), to discuss key operational, clinical, and quality related topics
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical record management, Availity, Quality resources, and member resources
• Communicate updates on Humana's policies and procedures and Cardinal Care programmatic updates
• Congregate periodic regional provider townhalls and/or trainings
• Ensure compliance with all Virginia managed care contractual requirements for provider relations, such as timeframes for claims dispute resolution, provider complaints, provider inquiry response, etc.

Requirements

Must reside in the Tidewater Region of Virginia
2+ years of health care or managed care experience working with providers (e.g., provider relations, claims education)
Experience working with physical health providers, facilities, ancillary providers, and/or FQHCs
Experience in provider operations, building strong relationships with provider organizations, financial/contracting arrangements, and/or regulatory requirements
Exceptional relationship management and interpersonal skills
Proficiency in analyzing, understanding, resolving, and communicating complex issues
Exceptional time management and ability to manage multiple priorities in a fast-paced environment
Thorough understanding of managed care contracts, including contract language and reimbursement
Exceptional written and verbal communication skills
Strong presentation and facilitation skills
Knowledge of Microsoft Office applications

Preferred Qualifications

• Experience with Virginia Medicaid
• Understanding of claims systems, adjudication, submission processes, coding, and/or dispute resolution
• Understanding of service coordination, prior authorizations, and other health plan processes
• Understanding of value-based payment programs

Additional Information

Must reside in the Tidewater Region of Virginia
Workstyle: This is a remote position that will require you to travel.
Travel: Up to 25% of the time to Humana Healthy Horizons office in Glen Allen, VA for collaboration and face to face meetings as well as field interactions with staff, providers, members, and their families.
Workdays and Hours: Monday – Friday; 8:00am – 5:00pm Eastern Standard Time (EST).