Major Responsibilities / Essential Functions

• Identifies provider trends, conducts market intelligence to understand key issues and reports to leadership
• Assist in clarifying state laws and Medicare/CMS and NCQA regulations/requirements regarding managed care as required
• Remain current and well-versed in organizational and departmental policies and procedures, and developments in products and benefits which impact contracted providers
• Maintain knowledge of policies and procedures relating to utilization management, referral process, and claim adjudication

• Schedule and perform initial orientation training to newly contracted network and affiliate providers, facilities, and individual practitioners
• Develop and maintain updates to training materials for use in large group or one-on-one settings
• Provide routine guidance to network providers and staff to become more self-sufficient in confirming eligibility, claims submission and payment by use of available tools
• Participate in the coordination of timely communication to introduce new products, insurance policy and procedure changes and updates on referral and utilization management protocols
• Develop content, edit and publish information in the Provider Manual and portals

• Build, support, and maintain critical relationships with network and affiliated practitioners, provider groups, hospital and facility organizations to ensure practitioner satisfaction and effective participation with all KP lines of business
• Facilitate partner meetings; Develop pertinent documentation for a service call in response to a specific provider request or routine office visit
• Conduct satisfaction surveys, assess results; develop and implement improvement plans

• Research, resolve and respond to provider inquiries and complaints from contracted network and affiliate providers related to billing, pricing, policy, systems, benefits, and reimbursement
• Identify, analyze and document root cause for issue and facilitate changes through key departments to prevent further incidences

• Work cooperatively with Network Operations Managers, cross-functional operational, insurance and physician teams to customer needs and improve processes

Department Operations

• Manage the day-to-day department operations, assuring quality customer service and support for clients and staff
• Develop a framework and associated templates for provider orientations, issue resolution and customer service requests/tracking
• Prepare reports and dashboards for leadership
• Mentor department staff to achieve optimal performance
• Assume responsibilities for Management in his/her absence

Minimum Education

• Bachelor's degree in healthcare, business or related discipline

Minimum Work Experience

• Minimum five (5) years of healthcare experience focused in provider relations, contract design/negotiation, claims processing, education/training or clinician facing customer service
• Minimum two (2) years in Provider Relations
• Minimum three (3) years progressive supervisory experience including allocating work assignments, conducting performance reviews, and providing performance coaching

Additional Requirements

• Excellent interpersonal and customer service skills required
• Ability to develop and maintain positive working relationships with both internal and external stakeholders
• Ability to work cooperatively, sensitively and tactfully while maintaining professionalism with all levels of staff and the general public required
• Understanding of health insurance claims, as well as an ability to analyze data to resolve provider service issues
• In-depth knowledge of healthcare issues and a variety of physician office procedures, concepts and practices
• Experience in leading and managing projects in a matrix environment
• Ability to operate in politically sensitive environment and navigate situations while maintaining positive relationships
• Strong presentation and training skills required in group settings
• Work with minimal guidance and escalate issues as appropriate
• Proficient with Microsoft suite of applications: Word, Excel, Desktop Publishing, Visio and Outlook
• Ability to deal with emotionally charged and difficult personalities with regards to claims payment and contractual issues
• Ability to travel to partner sites (at least 50%)

Required Licensure, Certification, Registration (LCR)

• Six Sigma or Lean Six Sigma Green Belt Certified within one (1) year in the role

Preferred Education

• Bachelors degree in healthcare, business, or insurance

Preferred Work Experience and Qualifications

• Minimum five (5) years of experience in provider relations
• Minimum two (2) years of experience in contract negotiation or design
• Experience in developing comprehensive training curriculum for internal staff and contracted providers
• Exceptional influencing and partnering skills at all organizational levels
• Ability to effect collaborative alliances, promote and foster teamwork
• Strong understanding of relational databases with desire to increase technical knowledge
• Ability to be resourceful, work independently, and manage time effectively
• Ability to delegate and handle multiple priorities
• Familiarity with CMS 5 Star, HEDIS, Risk Adjustment, and other Pay for Performance Programs desirable