SUMMARY:
The Provider Relations Representative (PRR) is a critical position to the overall success of the company. It is vital to establish and retain positive and successful relationships with the participating provider network. The PRR will possess excellent relationship building skills. This position requires someone with an outgoing personality, attention to detail, and firm understanding of the health care delivery system.

A. POSITION DUTIES & RESPONSIBILITIES:

a. Develop and maintain provider relationships and serve as a primary resource for information between the plan and provider network.
b. Investigate and resolve issues between the plan and provider network through monthly and quarterly visitation.
c. Dutifully ensure open lines of communication between the plan and provider network to address concerns, answer questions, and apprise offices of quality care metrics.
d. Ensure providers receive timely and accurate information regarding organization initiatives, services, programs, policies and procedures, and quality and productivity measurements.
e. Provide supervisor(s) with updates on assigned provider network per their request.
f. Respond to incoming phone calls and emails promptly.
g. Verify monthly provider effective dates, termination dates, open/closed panel status, demographic information, and health plan identification numbers.
h. Communicate and interact effectively with internal and external entities.
i. Play an active role in achieving PR Department goals.
j. Assist assigned provider network in improving quality and business processes.
k. Share improvement ideas with your PR supervisor/s and PR Department.
l. Assist with marketing the company by attending and participating in group events.
m. Coordinate, participate, and attend providers programs sponsored by company.
n. Review and report statistical data for potential chart review / audit of participating provider network.
o. Maintain and provide feedback on structured process for quality of audits, tracking and trending of provider metrics.
p. Ensure attendance by provider network to the provider educational and chart reviews programs.
q. Encourage provider network to increase membership and active participation.
r. Collect, document, and scan all charts retrieved from provider network to the appropriate locations as assigned by supervisor(s) or company.
s. Maintain detailed and accurate provider contact notes and ensure they are placed in the Carepointe Database.
t. Maintain monthly calendar for visitation timely through company software.
u. Maintain accurate mileage through the company mileage system.
v. Maintain accurate time keeping, following the company time keeping procedures when in/out of the office.
w. Work on special projects as assigned by supervisor(s) or company leadership.
x. Work collaboratively and constructively with all departments.
y. Complete other duties as assigned.

B. ROUTINE:

a. Know and follow Employee Handbook policies and procedures.
b. Communicate verbally and in writing through proper channels.
c. Maintain patient confidentiality. Be HIPAA compliant by observing HIPAA and group’s guidelines.
d. Use time clock appropriately.
e. Participate in staff meetings.
f. Follow dress code.
g. Notify supervisor in writing when requesting paid time off.
h. Be courteous.
i. Be flexible and adaptable.
j. Promote departmental and organizational goals.
k. Know and follow applicable safety standards.

C. PHYSICAL DEMANDS/WORK ENVIRONMENT:

a. Work Position:

i. Sitting – 50%
ii. Standing – 25%
iii. Walking - 25%

b. Body Movements:

i. Lifting 0-20 pounds; books, reams of paper, files, etc.- 30%
ii. Bending, stooping and squatting- 5%
iii. Reaching above head to 75 degrees less than- 5%
iv. Grip/hand dexterity; writing - 55%
v. Climbing stairs- 5%

D. KNOWLEDGE, SKILLS & ABILITIES:

a. Language & Communication Skills:

i. Excellent written and verbal communication skills.
ii. Maintain positive relationships through telephonic, face-to-face, and written communication.

b. Decision Making:

i. Ability to make decisions or solve problems by using logic to identify key facts, explore alternatives and propose quality solutions.
ii. Ability to maintain confidentiality.

c. Computer Skills:

i. Proficient in office equipment (computers, printers, etc.) and MS Office programs (Word, Excel, PowerPoint and Access).

d. Problem Solving:

i. Ability to find, gather and collect information or data.
ii. Ability to multi-task and prioritize in a high stress environment.

E. EDUCATION, TRAINING AND EXPERIENCE:

a. Associates degree or relevant equivalent experience.
b. Prior experience with provider networks and contracting with physicians.
c. Preferred knowledge of CPT, ICD, HCPCS, HCC coding; training may be available for the right candidate.
d. Knowledge of HMO, PPO, Medicare Risk and Indemnity products preferred; Accuracy and detail orientation (written and verbal).
e. Ability to interact with healthcare professionals.
f. Current unrestricted Arizona Driver’s license, reliable transportation and proof of
insurance required.

This description is intended to describe the essential job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not an exhaustive list of all duties, responsibilities and requirements of a person so classified. Other functions may be assigned, and management retains the right to add or change the duties at any time. The above expectations have been explained and discussed with me. I understand that my performance will be evaluated based upon these expectations.