Provider Relations Representative (Buffalo/WNY Territory)

Job Description:

This position serves as the primary contact between Providers and the organization. The position is responsible for servicing assigned providers within a defined geographic market. Key responsibilities include educating and servicing physicians, dentists, hospitals and ancillary providers within established guidelines. This position works closely with all other internal departments including sales, medical, operations and network management. As a key representative of the corporation, this position is expected to maintain strong communication and build positive working relationships with local physicians, hospitals and ancillary providers.

Candidate must reside in the Buffalo/WNY area in order to be considered.

Essential Accountabilities:

Level I:

• Recruit and retain all provider types to ensure network adequacy.
• Facilitates provider education and training through documented face-to-face visits, educational forums, and orientations in order to increase Provider’s knowledge and satisfaction with the terms of their contract as well as Health Plan's benefits products, policies, programs, systems, new programs and products.
• Provides orientation and training for all newly enrolled providers and their staff as well as annual training to the overall provider community.
• Educates providers on care management programs, policies, and quality initiatives including but not limited to UM programs, case and disease management, HEDIS, and paid for performance (P4P) in order to improve compliance and participation.
• Coordinates with Medical services to analyze and present data to providers in order to improve participation and/or compliance within established programs and enhance Member health status.
• Builds physician, provider and facility satisfaction by conducting service visits both in response to provider requests and proactively on behalf of the organization. Plans, initiates, develops, coordinates, schedules and documents visits in conformance with department standards and geographic assignment.
• Maintains awareness of competitive activity through relationships developed with providers and their office staff. On an ongoing basis, as part of monthly reporting, documents and shares information regarding market position including all competitive intelligence that would enable the organization to position ourselves favorably, as well as successfully respond to provider needs.
• Provides expertise and assistance with guidelines relative to provider billing and payment, encouraging participation with programs and procedures designed to create operational efficiencies. Ensures that changes in billing procedures are communicated on a timely basis to all providers. Provides accurate feedback to internal departments to improve accuracy of system interfaces.
• Serves as an internal expert and develops working relationships with internal departments in order to facilitate workflows and coordinate appropriate resources for problem resolution for providers. Identifies and communicates trends that impact provider satisfaction.
• Supports the development of effective provider tools and communications. Creates and maintains information such as provider manuals, newsletters, mailings, provider directories and other education and publication materials distributed by the organization to providers.
• Ensures that processes are being appropriately documented to support maintenance of the business.
• Assists with training and mentoring of peer Provider Relations Representatives as needed to ensure departmental success.
• Provides project management support as needed.
• Assists in developing and coordinating provider educational activities.
• Consistently demonstrates high standards of integrity by supporting the Lifetime Healthcare Companies’ mission and values, adhering to the Corporate Code of Conduct and leading to the
• Lifetime Way values and beliefs.
• Maintains high regard for member privacy in accordance with the corporate privacy policies and procedures.
• Regular and reliable attendance is expected and required.
• Performs other functions as assigned by management.

Level II (in addition to Level I Accountabilities)

• Represents the Provider Relations department on Health Plan projects/initiatives.
• Represents the Provider Relations department at Regional and Health Plan meetings as assigned by management.
• Develops, coordinates, and leads provider educational activities.
• Acts as the subject matter expert and point of contact for the department.
• Provides leadership and guidance to junior Provider Relations Representatives.

Level III (in addition to Level II Accountabilities)

• Leads Health Plan projects/initiatives that have a direct impact on improving provider satisfaction.
• Leads Provider Relations efforts to drive network and quality improvement.
• Represents Provider Relations Management, as assigned, in governance structure forums and strategic projects.
• Develops and nurtures positive relationships with strategic high profile providers, including full health system, provider partners and ACQA providers.

Minimum Qualifications:

NOTE: We include multiple levels of classification differentiated by demonstrated knowledge, skills, and the ability to manage increasingly independent and/or complex assignments, broader responsibility, additional decision making, and in some cases, becoming a resource to others. In addition to using this differentiated approach to place new hires, it also provides guideposts for employee development and promotional opportunities.

All Levels

• Bachelor’s degree in Business Administration, Health Care Administration or relevant field. Minimum of two (2) year’s relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
• In lieu of degree, individual must have experience that includes handling of escalated executive inquiries, training and/or presentations for staff or external customers.
• Demonstrated experience with moderately complex projects that involve both written and verbal responses to physician or hospital inquiries.
• Strong, persuasive and effective communication skills including previous experience with delivering communication to physicians and hospitals.
• Experience in preparing and delivering oral presentations to individuals and small and large group audiences.
• Understanding of medical care delivery and local market dynamics.
• Familiarity with provider contracts and operational policies and procedures.
• Understanding of products and services offered to Members.
• Understanding of claim processing systems including provider file and claim workflows.
• Knowledge of care management programs and their impact to Providers and Members.
• Strong interpersonal skills with ability to interface effectively both externally and internally with a wide range of people including physicians, office staff and other health plan staff.
• Excellent problem solving skills with effective follow through.
• Strong verbal and written communication skills; organizational and project management skills.

Level II (in addition to Level I Qualifications)

• Minimum of 4 year’s relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
• Demonstrated experience with complex and high profile projects that involve both written and verbal responses to physician or hospital inquiries.
• Working knowledge of provider contracts and operational policies and procedures.

Level III (in addition to Level II Qualifications)

• Minimum of 6 year’s relevant and progressive business experience working in managed care or other health care related field with significant interface with physicians and hospitals.
• Demonstrated experience with highly complex and high profile projects that involve both written and verbal responses to physician or hospital inquiries.
• Subject matter expert in care management programs and their impact to Providers and Members.

Physical Requirements:

• Ability to travel across the health plan service regions as needed.

In support of the Americans with Disabilities Act, this job description lists only those responsibilities and qualifications deemed essential to the position.

Equal Opportunity Employer

Compensation Range(s):

N7 Min: $23.56 - Max: $37.70

N8 Min: $26.89 - Max: $43.02

N9 Min: $29.57 - Max: $47.32

The salary range indicated in this posting represents the minimum and maximum of the salary range for this position. Actual salary will vary depending on factors including, but not limited to, budget available, prior experience, knowledge, skill and education as they relate to the position’s minimum qualifications, in addition to internal equity. The posted salary range reflects just one component of our total rewards package. Other components of the total rewards package may include participation in group health and/or dental insurance, retirement plan, wellness program, paid time away from work, and paid holidays. 

Please note: The opportunity for remote work may be possible for all jobs posted by the Univera Healthcare Talent Acquisition team. This decision is made on a case-by-case basis.

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.