Provider Relations Rep

Provider Relations Rep

CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto "Better. Together." is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.

Job Summary

The Provider Relations Representative is responsible for assisting with provider relations and service interactions to include but not limited to development and training of external provider education programs, identifying gaps in network composition and services and assists the network contracting staff in prioritizing contracting needs. The Provider Relations Representative assures that all provider orientations, site visits, access and availability studies are completed within compliance and established time frames. The incumbent may be involved in identifying and remediating operational short-falls and researching and remediating claims.

Position Responsibilities :

Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.

Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals / priorities for the department.

Develops and manages relationships with all network providers.

Performs outreach, monitoring and resolution of operational and / or contractual issues.

Identifies network gaps and performs recruitment to address community network needs.

Completes new provider orientation for all applicable product lines within the CalOptima Community Network.

Conducts site visits to service providers with training and education, resolves issues, educates, and interprets staff / providers on policies and procedures, collects credentialing information, and reviews Healthcare Effectiveness Data and Information Set (HEDIS) information.

Works with providers to adhere to contract, regulatory requirements and to communicate and meet the established CalOptima strategic goals.

Represents CalOptima at community and health plan-sponsored events.

Develops and delivers presentations on various CalOptima topics to the provider community.

Other projects and duties as assigned.

Possesses the Ability to :

Communicate clearly and concisely, both verbally and in writing.

Establish and maintain effective working relationships with CalOptima leadership and staff.

Plan and facilitate meetings as well as prioritizing tasks in order to meet challenging deadlines.

Participate in audits and readiness assessments to assess contract compliance.

Coordinate and collate informational materials appropriate for the targeted audience.

Utilize computer and appropriate software (e.g. Microsoft Office : Word, Outlook, Excel, PowerPoint) and job specific applications / systems (e.g., FACETS) to produce correspondence, charts, spreadsheets, and / or other information applicable to the position assignment.

Have a valid driver's license and vehicle, or other approved means of transportation, an acceptable driving record, and current auto insurance will be required for work away from the primary office 30% of the time or more.

Experience & Education :

Bachelor's degree in Business Administration or related field or equivalent combination of education and / or experience in Health Care Administration required.

2 years of experience in the Health Care field or Managed Care required.

Knowledge of :

Principles and practices of Medi-Cal requirements.

Health care services delivery model (capitation vs. fee-for-service, staff physician models, Medicare, Medi-Cal, Cal MediConnect, commercial plans, etc.).

Guidelines and regulations specific to the health care field.

Claims and authorization processes (general knowledge).

Department(s) : Provider Relations

Reports to : Manager, Provider Relations

FLSA status : Non-Exempt

Salary Grade : G - $26.44 - $37.55 ($55,000 - $78,100)

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion / religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Job Location : Orange, California