Provider Relations Field Representative

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This position is responsible for both the negotiation of physician/provider contracts and ongoing education/service to the physician/provider network in assigned market areas.

 

Responsibilities include but are not limited to:

 

Conduct a quarterly audit for each line-of-business and provider category to determine ongoing network needs and provide written network development goals.

 

Identify, on a semi-annual basis, opportunities for re-negotiation of contracts by line-of-business and provider category and written re-negotiation goals.

 

Negotiate contracts within approved rate reimbursement arrangements unless approved by the Department Manager.

 

Negotiate out-of-network contracts and rates, maintain a log of these negotiations, determine the ongoing need for the physician/provider and conduct negotiations for a contract (if appropriate)

 

Negotiate rates that will achieve yearly department goals for Medical Loss Ratios (MLR)

 

Upon completion of the negotiated contracts, be responsible for obtaining correctly completed credentialing applications with supporting documents.

 

Upon approval by the Credentialing Committee, conduct New Office Orientation programs for all participating physicians/providers and their staff.

 

Utilizing service guidelines, maintain network stability as it relates to physician/provider terminations and panel closing by primary care physicians.

 

Develop and implement, through service visits, educational tools for physicians/providers and their practice staff.

 

Work closely, in assigned markets, with the Marketing Department staff and primary care physician practices to achieve/exceed membership growth projections.

 

Conduct monthly service/educational visits to high volume/key specialty offices as identified by the Department Manager.

 

Conduct monthly service/educational visits to primary care physician offices with more than 100 enrolled members and every-other-month visits to primary care physician offices with fewer than 100 enrolled members.

 

Work in cooperation with the assigned Claims Department staff, conduct monthly service/education visits to all participating hospital Billing Departments.

 

Manage providers demographic information changes (tax ID numbers, new address, etc.) and resolve identified problems.

 

In conjunction with the Department Manager, develop and implement strategies for reduction of MLR's in identifed primary care physician practices.

 

Abide by all compliance requirements for the Department of Insurance (DOI), Agency for Health Care Administration (AHCA) and the Centers for Medicare and Medicaid Services (CMS) as these apply to Provider Relations Department activities.