Provider Relations Representative - External

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California and future increases will be based on the pay band for the city and state you reside in.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work - Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP's focuses on 5 Core Values in the workplace:

* Integrity

* Accountability

* Collaboration

* Trust

* Respect

Disclaimers:

* Flexible work schedule is based on job duties, department, organization, or business need.

* Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Provider Relations Representative-External is a field-based position is responsible for ensuring effective communication, compliance, and support for network providers, dedicating a minimum of 75% of time to provider visits, community engagements, and on-site activities. As the primary liaison between providers and the organization, the representative is tasked with resolving inquiries, facilitating onboarding processes, and delivering targeted education on policies, regulatory requirements, and reimbursement methodologies. Through proactive collaboration with internal departments, the representative ensures seamless coordination for claims resolution, contracting questions, and data management.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

* Initiate and maintain effective channels of communication with GCHP network providers.

* Provide the onboarding of new GCHP network providers to ensure full compliance with regulatory requirements.

* Travel to provider offices at a minimum of 4 working days per week.

* Build and nurture relationships with healthcare providers, community-based organizations, and other key stakeholders in the designated region to promote the health plan's goals and ensure robust network participation.

* Act as a primary external point of contact for provider inquiries, resolving issues promptly. Educate providers on health plan policies, procedures, and compliance requirements to enhance efficiency and service delivery.

* Represent the health plan at local events, health fairs, and professional gatherings. Develop and deliver presentations to increase awareness and advocate for the organization's services within the community.

* Conduct regular provider visits to gather data, identify trends, and assess provider performance. Provide actionable insights and detailed reports to internal teams to support strategic decision-making.

* Work closely with cross-functional teams, including internal provider relations teams, operations, and customer service, to align provider activities with GCHP goals and improve the overall provider experience.

* When required, assist departmental operations with investigating contracting questions, including interpretation of contract language as it pertains to the roles and responsibilities of a GCHP network provider, coding and reimbursement methodology.

* Manage and maintain GCHP network provider data and rosters to ensure additions and terminations of participating providers, address/demographic changes, name changes, TIN, NPI updates and provider practice information changes are timely and accurately submitted to all applicable operational systems.

* Facilitate first call resolution, when appropriate, for GCHP provider questions and concerns.

* Drive the resolution of escalated questions and concerns efficiently by actively engaging with providers, claims, contracting, and health services departments, ensuring clear and effective communication across all parties.

* Gather, review, and submit relevant documentation needed for to help resolve complex claims inquiries and/or claims processing.

* Educate healthcare providers about Medicare Risk Adjustment (MRA) including but not limited to accurate documentation, coding.

* Educate healthcare providers on CMS guidelines, compliance requirements and risk adjustment audits and reviews.

* Coordinate prompt claims resolution through direct communications with providers, claims, contracting and health services departments.

* Be proficient and maintain knowledge of basic claims processing, components of claims submission, processing, payment and reimbursement methodologies and issues resolution.

* Organize, schedule, and develop training sessions for joint operation meetings, individual provider trainings, and group provider trainings.

* Provide documentation and reports for internal GCHP committees, detailing provider trainings, contacts, and follow-ups.

* Consistently monitor and manage the provider roster, ensuring timely follow-ups and oversight.

* Maintain understanding of applicable federal, state, and local laws and regulations regarding healthcare with a focus on Medicaid and Medicare.

* Notify departmental colleagues and/or leadership of potential issues, shortfalls, and trends in GCHP provider network to help initiate improvement opportunities.

* Assist departmental colleagues on training of contract inquiries and/or contract issues that impact GCHP network providers' roles and responsibilities.

* Manage disputes diplomatically to find mutually beneficial solutions.

* Articulate information, updates and policies to ensure providers understand expectations and requirements.

MINIMUM QUALIFICATIONS

Education & Experience: Please identify the nature of education and experience such as: Associates, Bachelor's and/or Master's degree (four-year college or technical school) and list any applicable specialty or field of study.

* High School Degree

* Minimum 5+ years health care/managed care experience to include: Experience in provider relations, healthcare administration, health related customer service or a related field.

* Proficient knowledge of governmental lines of business (Medicare and Medicaid)

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

* Bachelor's Degree (four-year college)

* Understanding with claims processing, reimbursement methodologies, and healthcare regulations.

* Proven track record of building and maintaining relationships with healthcare providers or clients.

* Experience in training, onboarding, or educating providers on policies, procedures, and compliance requirements.

Technology & Software Skills: Advanced computer skills included in the MS Office products, specifically Word, Excel, PowerPoint, Teams and Outlook

Certifications & Licenses: A valid and current Driver's License, Auto Insurance

Professional licensure: N/A

Competency Statement(s) - Select all that apply.

* Management Skills - Ability to organize and direct oneself.

* Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.

* Customer Oriented - Ability to take care of customer needs while following company procedures.

* Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

* Interpersonal - Ability to get along well with a variety of personalities and individuals.

* Time Management - Ability to utilize the available time to organize and complete work within given deadlines.