Provider Relations Account Manager

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP's focuses on 5 Core Values in the workplace:

* Integrity

* Accountability

* Collaboration

* Trust

* Respect

Disclaimers:

* Flexible work schedule is based on job duties, department, organization, or business need.

* Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Provider Relations Account Manager oversees development and implementation of provider network and contract strategies required to serve the health care needs of GCHP membership to meet or exceed applicable access criteria and adequacy standards for covered services. The role is accountable for the overall provider experience by working in collaboration with matrix internal and external partners to drive on-going service improvements, understand, articulate and resolve service impacts, and drive the overall provider strategic planning solutions. This role is empowered to guide, and make decisions as it pertains to the growth, operational processes and standards identified by GCHP.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Job Function & Responsibilities(s)

* Act as the primary liaison for assigned providers, handling inquiries related to network participation, reimbursement, claims, and operational processes.

* Accountable for the end-to-end provider experience and overall service delivery for assigned medium to complex providers

* Address provider inquiries related to network participation, reimbursement, claims and operational processes.

* Creates and maintains and manages provider strategic action plans.

* Proactively identify market, state or national risks for providers and drives resolution in collaboration with assigned provider.

* Serve as external facing liaison with assigned providers.

* Track, monitor and analyze provider performance, complains and issue resolution trends for assigned providers.

* Promote quality score improvement through proactive and effective service and support of network.

* Prepare and present provider reports/dashboard on key account performance, contract outcomes and strategic initiatives.

* Serve as a provider advocate both internally and externally.

* Manage the research of issues that may impact future provider negotiations or jeopardize network retention.

* Responsible for monitoring of internal GCHP department metrics, including claims, operations, health services and oversight of operational activities for the group.

* Provide feedback to assigned provider on overall performance status

* Functions as a high level GCHP resource to resolve or facilitate complex provider issues

* Serves in a consultative role or subject matter expert to key matrix partners

* Responsible for monitoring department metrics, provider assignments and oversight of daily activities and provide feedback to manager on performance management, day-to-day training, guidance, and workflow of Provider Experience Consultants and Provider Experience Managers

* Monitor provider performance, metrics, and overall performance management on CMS Star Ratings, HEDIS, CAHPS and other Medi-Cal quality and operational requirements.

* Analyze provider feedback and operational data to identify areas for improvement and implement solutions.

* Manage and assist the process for required corrective action plan implementation and monitoring, education, contract questions and non-routine claim issues.

* Manage and deliver provider orientations and ongoing trainings which includes focus on Medicare and Medicaid regulatory updates and operational workflows, agenda development, facilitation of appropriate meeting participation and follow up activities

* Contributes as a key member of the department's leadership team and participates in committees addressing the department's strategic goals and organization.

* Manage and or provide training and guidance as needed to the internal GCHP teams.

* Manage the onboarding of new GCHP network providers to ensure full compliance with regulatory requirements.

* Build and nurture relationships with healthcare providers, community-based organizations, and other key stakeholders in the designated region to promote the health plan's goals and ensure robust network participation.

* Manage and act as a primary external point of contact for provider inquiries, resolving issues promptly.

* Facilitate and educate providers on health plan policies, procedures, and compliance requirements to enhance efficiency and service delivery.

* Conduct and manage regular provider meetings to gather data, identify trends, and assess provider performance. Provide actionable insights and detailed reports to internal teams to support strategic decision-making.

* Foster relationships with healthcare providers, community-based organizations, and key stakeholders to strengthen network participation.

MINIMUM QUALIFICATIONS

Education & Experience:

* High School degree

* 5+ years of experience in provider relations or healthcare required

* Working knowledge of Medicaid/Medi-cal

Equivalent In lieu of degree:

* May accept degree in lieu of work experience, which demonstrates the ability to perform the duties of the position.

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

* Bachelor's degree strongly preferred

* Must have demonstrated working knowledge of Medicare

* Demonstrated knowledge and experience in fostering ongoing relationships and beneficial partnership between GCHP and providers.

* Experience with investigating and resolving provider claims, billing, system and payment issues.

* Experience on health plan provider portal and functionalities and collaboration with vendors for resolution of technical issues.

* Excellent communication, problem solving and relationship management skills

* Ability to interpret and apply healthcare regulations and policies

* Managed technical aspects of provider relations, including system enhancements and implementation, data analytics, and reporting

* Demonstrated technical knowledge and work with other departments for system set up and configuration

* Ability to work in a matrix environment.

* Demonstrated ability to manage multiple projects and identify opportunities for internal and external collaboration.

Technology & Software Skills: Advanced computer skills in MS Office products.

Certifications & Licenses: A valid and current Driver's License, Auto Insurance, and professional licensure(s)

Competency Statement(s)

* Management Skills - Ability to organize and direct oneself and effectively supervise others.

* Business Acumen - Ability to grasp and understand business concepts and issues.

* Decision Making - Ability to make critical decisions while following company procedures.

* Goal Oriented - Ability to focus on a goal and obtain a pre-determined result.

* Interpersonal - Ability to get along well with a variety of personalities and individuals.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

* Consensus Building - Ability to bring about group solidarity to achieve a goal.

* Relationship Building - Ability to effectively build relationships with customers and co-workers.

* Presentation Skills - Ability to effectively present information publicly.

* Delegating Responsibility - Ability to allocate authority and/or task responsibility to appropriate people.

* Leadership - Ability to influence others to perform their jobs effectively and to be responsible for making decisions.

* Strategic Planning - Ability to develop a vision for the future and create a culture in which the long-range goals can be achieved.

* Ethical - Ability to demonstrate conduct conforming to a set of values and accepted standards.

* Judgment - The ability to formulate a sound decision using the available information.

* Communication, Oral - Ability to communicate effectively with others using the spoken word.

* Communication, Written - Ability to communicate in writing clearly and concisely.

* Problem Solving - Ability to find a solution for or to deal proactively with work-related problems.