JOB SUMMARY: The Senior Provider Relations Representative is office-based and is responsible for resolving Physician, Hospital, Ancillary, and Physician organization (Provider) focused issues including, but not limited to educational needs, contract verification, participation status, claims payment discrepancies, interaction with Community's provider portal, and questions regarding Community's process for obtaining authorizations. The Senior Provider Relations Representative exhibits good communication and interpersonal skills; maintains a working knowledge of the designated QNXT referral, claims, eligibility, and provider modules, as well as all CACTUS modules, and serves as the primary party responsible for responding to inquiries referred to Provider Relations. The Senior Provider Relations Representative ensures that new Providers receive the required initial education materials, i.e., Provider Manual, Quick Reference Guides, etc.; supports the Provider Engagement Representatives and Provider Relations Representatives by monitoring and reporting educational needs identified through web inquiries, reports, and other analytical measures; may provide guidance or expertise to fellow team members. Works closely with management or takes the lead to create, maintain and update provider communications including, but not limited to provider notices, provider manuals, quick reference guides, and orientations as required by URAC, NCQA, TDI, HHSC, CMS, and other regulatory agencies. Collaborates with leadership, co-workers, and staff in other departments to achieve departmental and organizational objectives.
MINIMUM QUALIFICATIONS:
1. Education/Specialized Training/Licensure: High School or equivalent required. BA/BS in Business preferred
2. Work Experience (Years and Area): 5 years' experience in managed care (Provider Relations/Services; Claims Adjudication, Medical Coding, Contracting)
3. Management Experience (Years and Area): N/A
4. Software Operated: Microsoft Office (Word, Excel, Outlook and PowerPoint), QNXT and CACTUS systems preferred
SPECIAL REQUIREMENTS: (Check Applicable Areas)
1. Communication Skills:
Above Average Verbal (Heavy Public Contact)
Writing /Composing: Correspondence / Reports
2. Other Skills: Medical Terminology, Statistical, MS Word, MS Excel, MS PowerPoint
3. Advanced Education:
Bachelor's Degree Major: Preferred
4. Work Schedule: Flexible
RESPONSIBLE TO: Director