Provider Relations Representative
On-siteCoral Gables, Florida, United States
Job Summary
Conduct provider orientations for newly contracted providers and secure signed acknowledgements within specified policy time frames. Maintain original copies of educational forms and disseminate the Provider Handbook, bulletins, and applicable policies to the network. Perform annual and periodic site visits for Primary Care Physicians and high-volume specialists, completing required tools and monitoring after-hours survey accessibility against CMS standards. Oversee assigned provider accounts, ensure all communication materials remain current, and coordinate benefit presentation meetings. Address provider complaints and disputes, participate in Quality Management initiatives, and report on corrective action plans and claim settlements. Maintain proficiency in Federal and State regulatory subject matters governing Medicare Advantage operations.
Required Qualifications
- 3 - 5 years' experience with a Medicare Advantage Health Plan
- BS/BA Degree
- Commitment to the Health Plan's vision and mission
- Excellent communication skills, both in oral and written
- Demonstrable knowledge of provider reimbursement methodologies applicable to Medicare Advantage Health Plans and other federal health insurance programs
- Knowledge of CMS, AHCA and other federal and state current regulatory governing guidelines applicable to HMOs
- Excellent organizational skills
- Flexible Disposition to enable management of special projects
- Excellent Customer Service Skills to enable resolution of complex and varied situations involving multiple internal and external stake holders
- Ability to drive key organizational / operational initiatives
Desired Qualifications
- Fully Bilingual English / Spanish (preferred)
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