Provider Relations Representative 8/10/2016
JOB DESCRIPTIONAPPLY FIDELIS CARE OFFERS QUALITY, AFFORDABLE COVERAGE TO RESIDENTS ACROSS THE STATE OF NEW YORK, INCLUDING PRODUCTS AVAILABLE THROUGH MEDICAID, MEDICARE AND THE NY STATE OF HEALTH. FIDELIS CARE WAS FOUNDED ON THE BELIEF THAT ALL NEW YORKERS SHOULD HAVE ACCESS TO AFFORDABLE, QUALITY HEALTH INSURANCE AND THAT REMAINS OUR MISSION TO THIS DAY TO OUR MORE THAN 1.4 MILLION MEMBERS.
Assures that all provider orientations, site visits, access, and availability studies are completed within established timeframes; establishes and fosters strong positive relationships with key providers by coordinating and facilitating meetings and identifying onsite enrollment opportunities.
* Assure that all provider orientations, site visits, access and availability studies are completed within designated timeframes; assure that all providers are visited within established timeframes.
* Facilitate retrieval of Fidelis Care New York's member healthcare records to ensure achievement of optimum QARR scores.
* Conduct Access and Availability studies as needed; conduct Delegated Credentialing audits and on-site provider office assessments required for credentialing.
* Complete credentialing and re-credentialing audits for delegated providers.
* Investigate and resolve member complaints regarding providers to maintain member and provider satisfaction; clarify the provider's problem; determine the cause of the problem; select and explain the best solution to solve the problem and expedite correction or adjustment; follow up to ensure resolution.
* Assist Contract Management in identification of network deficiencies and make recommendations on how to address them.
* Establish and foster strong, positive relationships with key providers by coordinating, facilitating and leading partnership meetings and identifying onsite enrollment opportunities for Marketing.
* Proactively identify provider needs and advise management so that action can be taken to address the needs before they are problematic for the provider.
* Educate providers on the Plan's provider incentive programs.
* Proficiency in Microsoft Office: Excel, Word, Access; Lotus Notes; Internet.
* Knowledge of various quality programs, including measures associated with QARR and HEDIS.
* Knowledge of various provider payment methodologies.
* Business Analysis Knowledge: Skilled to work in a fast paced environment. Must have strong analytical and problem solving skills.
* Customer Service: Skilled to communicate with all levels of management, internal and external customers.
* Ability to work well as a member of a team or alone.
* Effective Business Communication: Skilled in communicating with technical and business constituencies in writing effective business specifications and requirements.
WORK RELATED EXPERIENCE:
* Three to five years experience working in a managed care environment serving in Provider Relations, Contract Management, or equivalent role.
* Five to eight years related experience required.
* Education, License, and Certification Requirements:
* BA/BS - Bachelors Degree or equivalent required.