Provider Relations Representative
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Saco, ME 04072
Manages provider Network performance for assigned territory with an account management approach. Achieves market performance targets through the implementation and execution of Network transformation strategies in order to improve overall Network performance.
Key Duties and Responsibilities
• Owns and manages contractual relationship and performance of assigned in-network provider groups. Serves as primary point of contact for assigned providers.
• Evaluates provider performance via Enterprise Provider Dashboard and develops performance action plans.
• Completes new provider orientation for all applicable product lines to educate on policies and initiatives, resolve issues, and educate staff/providers. In addition, drives adoption and utilization of RxEffect, P4Q, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, etc.
• Establishes consistent and strong relationships with provider groups utilizing an account management approach.
• Establishes and leads cross-functional communication with internal departments.
• Collaborates with internal cross-functional team to support provider performance and resolve barriers and challenges.
• Drives improvement of provider performance by analyzing, interpreting, communicating utilization and quality metrics.
• Responsible for developing and executing performance improvement plans.
• Understand and explains fee-for-service reimbursement to providers and management.
• Understands fee-for-service contractual arrangement and works with internal support team to resolve provider contractual inquiries.
• Plans, prepares and executes effective group meetings/discussion with proper objectives and expected outcomes with internal and external customers.
• Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.
• Provides continual training to assigned providers on wellcare.com portal and other resources to assist with claims, authorizations, member benefits, etc.
• Provides oversight of delegated functions, as applicable.
• Performs special projects as assigned.