Provider Relations Specialist

2 weeks ago

Chula Vista, California, United States Community Health Group Full time
Job Overview

POSITION SUMMARY

The Provider Relations Specialist plays a crucial role in addressing and resolving issues faced by healthcare providers, ensuring they remain informed about relevant policies, procedures, and contractual updates. This position is responsible for coordinating educational initiatives and training for providers while disseminating vital information regarding Medi-Cal managed care and Community Health Group (CHG) to beneficiaries, community organizations, and the public. Building and maintaining positive relationships with providers and community organizations is essential for enrolling Medi-Cal beneficiaries interested in CHG.

REGULATORY COMPLIANCE

This role requires close collaboration with various departments to ensure that utilization management processes, programs, and services are executed efficiently and in a timely manner. Adherence to CHG policies and compliance with applicable state and federal regulations, including CMS, DMHC, and DHCS, is mandatory.

KEY RESPONSIBILITIES

  • Enhances organizational visibility through individual and group presentations, as well as outreach efforts to providers and community organizations.
  • Establishes and nurtures positive relationships with providers, ensuring timely resolution of concerns through regular site visits.
  • Addresses and resolves day-to-day operational issues faced by providers.
  • Communicates updates and alerts to keep providers informed about procedures related to Claims, Customer Service, HEDIS, and more.
  • Collaborates with Claims, Customer Service, Contracting, and other departments to ensure accurate resolution of provider-related contract issues.
  • Implements and provides feedback on policies and procedures related to provider management.
  • Promotes CHG's Medi-Cal health plan by organizing and participating in community health fairs and events.
  • Facilitates the enrollment of Medi-Cal beneficiaries interested in joining CHG.
  • Contributes to team efforts by performing additional duties as assigned, participating in meetings and committees, attending workshops, and pursuing professional development opportunities.
  • Maintains a professional image and upholds the reputation of the organization at all times.

EDUCATION

  • Bachelor's degree is preferred.

EXPERIENCE AND SKILLS

  • Valid CA driver's license, proof of auto insurance, and reliable transportation.
  • Minimum of one year of successful sales experience.
  • At least two years of successful community outreach experience, ideally related to Medi-Cal and/or Medicare.
  • Familiarity with Medi-Cal managed care eligibility requirements and CHG programs and services.
  • Knowledge of community social service organizations.
  • Bilingual proficiency in Spanish or Vietnamese is required.
  • Self-motivated with the ability to identify and leverage opportunities to promote CHG programs in various settings.
  • Proficient in Microsoft Office Suite (Word, Excel, Access, etc.).
  • Strong written, verbal, and telephone communication skills.
  • Adept at analyzing program requirements and regulations, understanding contract language, and educating providers on related matters.
  • Capable of managing multiple tasks simultaneously.
  • Skilled in identifying issues and resolving complex problems with both internal and external stakeholders.
  • Experience in conducting effective sales presentations.
  • Ability to prepare training materials and educate staff.

PHYSICAL REQUIREMENTS

  • Frequent travel required.
  • Public speaking engagements.
  • Ability to work evenings and weekends as necessary, including transporting equipment for community events.
  • Capability to lift and carry up to 30 lbs.

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