Provider Relations Field Representative

Summary of Position

• Highly visible, external-facing, field-based role, serving as the primary contact and resource for fee-for-service or value-based
  providers in assigned territory, with focus on government programs (Medicaid, HARP, Essential, CHP, Medicare).
• Under minimal direction, works directly with providers to maintain highly satisfying and functioning relationships, engaging
  with medical office staff, senior leaders, and physicians.
• Demonstrated subject matter expertise in organizational processes, policies, programs, and provider-facing tools enabling
  on-the-spot training and education as needed, including onboarding, management of the business relationship and
  performance, and issue resolution.
• Develop relationships that drive growth efforts proactively.
• Increase provider effectiveness through promotion of organizational quality, risk adjustment (condition coding accuracy),
  administrative cost effectiveness, and provider/member satisfaction initiatives.

Principal Accountabilities

• Conduct a minimum of 10 on-site visits per week with designated high-touch providers to assist with provider issues,
  education materials, communication of EmblemHealth policies and procedures, contractual obligations, and
  organizational strategic initiatives.
• Educate on processes including claims submissions, recoupments, reconsiderations, authorizations, referrals, medical
  record management, quality resources, and member resources.
• Meet regularly with assigned providers to conduct training and education, such as required annual trainings, systems
  training, and electronic solutions (EDI, EFT, EMR, Provider Portal, Tableau reports/dashboards)
• Onboard new providers, including in-person sessions or hosting orientation webinars to educate providers on location
  and content of all provider-facing materials (Orientation, Provider Manual, Newsletter, Program Updates, etc.).
• Coordinate with various functions within the organization (e.g., claims, operations, enrollment, customer service,
  medical management, vendor management) to ensure appropriate and prompt handling/resolution of provider issues,
  inquiries and complaints, while balancing provider needs with organizational priorities.
• Take initiative in preventing and resolving issues between the provider and the Plan whenever possible, and
  independently troubleshoot problems and drive resolution.
• Initiate, coordinate and participate in problem-solving meetings between the provider and internal stakeholders as
  necessary
• Support achievement of organizational strategic goals, including organic growth, performance (quality, coding
  accuracy, efficiency), and satisfaction.
• Deliver actionable data to providers on value-add opportunities and incentive programs.
• Support network development initiatives, including roll-out of new benefit plans, network sculpting and expansions.
• Ensure regulatory and provider network compliance requirements are met for assigned providers.