- Full Time/Contract
- Provider Relations
- Rancho Cucamonga, CA
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company To Work For , "Favorite Training Program , and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.
Provider Services Delegated Coordinator
The Provider Relations Coordinator is responsible for supporting the Provider Services Representative (PSR) team and its Provider training initiatives through the processing of Member and Provider cases, response to Provider inquires and concerns, processing of Provider information and special projects as assigned
- Responsible for reviewing and resolving cases and inquiries from Member Services and other Company departments in CRM on behalf of the Provider Services Representative (PSR) team, particularly as back up for PSRs who are in the field for Provider trainings.
- Responsible for understanding the Pay for Performance (P4P) Program and its guidelines in order to advise on questions from providers as well as review P4P Program payment appeals. Present P4P appeal trends or concerns to the PSRs and management in order for PSRs to follow up with trainings and visits to Providers as needed.
- The Coordinator must have vast knowledge of the information contained in the Company Provider Manual and must be proficient in navigating the Provider Portal.
- Assist PSRs under the direction of the Provider Relations Supervisor and Provider Relations Manager in organization of documents scanned and kept electronically.
- Assist PSRs under the direction of the Provider Relations Supervisor and Provider Relations Manager in follow up of re-credentialing applications.
- Support LEAN activities by actively participating in LEAN initiatives, RIEs, daily huddles and provide feedback during participation.
- Send Member grievances against Company Direct Providers to the appropriate physicians for their timely responses. Coordinate with PSRs to educate Direct Providers on grievance timeframes and training to address grievance root issues in order to improve Provider service to Members.
- Serve as back-up to Provider Services specialists in remediation of Closed PCP cases tasked to Provider Services.
- Assist Provider Relations Trainer under direction of the Provider Relations Manager in compilation of resources and administrative organization of training materials and job aids.
- Work promptly on any other designated requests or projects received from the Provider Relations management team to ensure Member’s care is not delayed or compromised and Provider concerns are resolved. In addition, work on requests or projects such Provider Directory outbound calls and updates, P4P packets, etc, as directed by the Provider Relations management.
Possession of a high school diploma or equivalent. Associate or Bachelor Degree preferred.
Three (3) or more years of experience in an office environment and experience in a managed care environment preferred.
Three (3) or more years experience with customer service.
Microcomputer Applications (Microsoft Word and Excel, Access preferred) for use in all aspects of an office environment.
- Familiar with PC computers running Microsoft Windows; Microsoft Excel, Microsoft Word, Microsoft Access and Power Point. Knowledge of managed care practices.
- Ability to gather and analyze data in a detailed and highly organized manner. Professional demeanor. Excellent interpersonal/communication skills, problem solving capabilities, ability to establish and maintain effective working relationships, trustworthy, reliable and an independent worker.
Full Time, Contract