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Overview:

To establish and maintain excellent relationships with the healthcare provider network in a specific geographic region, including healthcare practitioners, office staff, and administrators. Works closely to identify and resolve complex issues, provides education and staff training. Provides service and education via onsite visits and telephone. Assists providers with understanding managed care of California's policies and procedures and assists with resolving issues that arise. Supports provider contract negotiation, review, renewal, and resolution of contractual issues.

Responsibilities:

Investigates and responds to provider concerns. Serves as a liaison between providers and SPN,IPA departments in responding to questions and resolving issues. Assists with research and disposition of provider appeals and grievances.
Identifies network gaps and performs recruitment to address community network needs.
Negotiates, reviews, and manages provider contracts and agreements, including reimbursement rates, contract terms, amendments, renewals, and other contractual requirements. Works directly with providers and internal departments to negotiate agreements and resolve contractual issues.
Build and maintains relationships with all network providers.
Trains provider /ancillary offices via onsite visits and by telephone regarding SPN IPA policies, procedures, and available resources, referral, claim processing, portal access.
Creates educational materials and formal presentations.
Conducts and maintains office site visits to service providers with training and education, resolves issues, educates and interprets staff/providers on policies and procedures, collects credentialing information and reviews Healthcare Effectiveness Data and Information Set (HEDIS) information.
Educates providers on the use of IPA provider information forms. Follows up with providers on incomplete forms to obtain required information.
Resolves complex authorization or claims issues. Identify potential system issues, collaborate with affected departments to ensure resolution.
Conducts, quarterly utilization management meeting, annual and ad hoc, and provider/ member surveys. Coordinates, attends, and participates in various meetings both on and off-site as assigned.
Creates Corrective Action Plans (CAPS) for provider sites that did not meet standards. Monitors compliance with CAP.
Uses databases and tracking systems to document and retrieve information and run reports.
May be required to report on major points, resolved and pending action items.
Required to work with minimal supervision.
Other duties as assigned.

Qualifications:

Education and Experience:

Bachelor’s degree in health care administration, business, or public relations preferred, or equivalent combination of education and experience; prior experience with physician offices or managed care, IPA or health insurance environment preferred. At least 3 years minimum experience.
Demonstrated experience negotiating healthcare provider contracts, including reimbursements rates, contract terms, amendments, and renewals.

Requirement:

Excellent oral and written communication and presentation skills.
Excellent organizational, prioritizing, and multi-tasking skills required.
Ability to use good judgment in making decisions within scope of authority and handle sensitive issues with tact and diplomacy.
Proficient in Microsoft Office (Word, PowerPoint, Excel).
Ability to use a variety of databases for research and entry of information.
Valid California driver’s license and proof of current automobile.
Must be able to work in a fast-paced environment and maintain courtesy and composure.
Ability to function effectively with frequent interruptions.
Negotiation experiences a required qualification a must.

Work Environment And Physical Demands:

Hours: Mon – Friday 40 hrs. a week.

Paid: Holidays, Vacation and Sick Days.

At least 50% of work time is spent driving and more than 30% of work time is spent in office. Ability to lift, carry or move objects of varying size, weighing up to 15 lbs.

Compensation between $25 and $30/hr x 40 hours a week.

Medical, Dental and Vision insurance available after 90 days. 401K after 6 months.

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