Santaclara Family Health Plan
Provider Network Associate
Santaclara Family Health Plan, San Jose, California, United States, 95111
FLSA Status: Exempt
Department: Provider Network Management
Reports To: Director, Provider Network Management or Operations Director, MLTSS
Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
GENERAL DESCRIPTION OF POSITION
The Provider Network Associate will serve as a liaison to SCFHP's network of providers, hospitals, sub-acute facilities and health systems, including medical groups, independent clinics, mental health professionals, and ancillary providers. The Provider Network Associate will be an integral part of the Provider Network Management and MLTSS teams and will provide exemplary customer service and training to all providers in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.
* Represent SCFHP in the provider community, including but not limited to, representing the department and SCFHP at internal and external meetings and events.* Via telephone and in person, act in the capacity of primary provider liaison and SCFHP subject matter expert by responding to and resolving complex provider questions and complaints/problems in an efficient and timely manner.* Assist providers to navigate SCFHP operations provider network systems, compliance and regulations.* Communicate clearly and concisely with providers at all levels, including administration, the business office and relevant vendors. Accurately capture and document issues and feedback. Convey information to other departments and organizational leadership when appropriate.* Collaborate with Provider Network Management and MLTSS team members to coordinate resolution of operational issues with internal departments and cross-departmental improvement efforts.* Assist with the development and monitoring of the provider network to identify issues related to network adequacy and/or access issues and take action, as needed to improve quality access to medical services and improve member satisfaction.* Create and deliver SCFHP provider orientation and training within established timeframes. On an annual basis, develop and execute provider communication plans including a schedule of site visits, trainings and meetings necessary to execute on the communication and training strategies.* Maintain knowledge of SCFHP's departmental functions and processes that enable research and identification of operational issues related to claims, authorizations, member grievances, provider disputes, and quality.* Build and maintain expertise and understanding of managed care, SCFHP policies and procedures and relevant regulatory requirements. Incorporate knowledge into the development of provider training and communication tools to improve compliance.* Create and participate in staff training. Assist with new hire training by allowing new Provider Services Representatives to shadow and observe performance and provide feedback to management.* Attend and actively participate in Provider Network Management and MLTSS meetings, other SCFHP operational meetings, training and coaching sessions, including off-site meetings as needed.* Initiate and manage process improvement projects in response to identified complex operational issues, trends or regulatory changes.* Perform other related duties as required or assigned.
REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
* Bachelor's Degree in Social Sciences, Business, or related field, or equivalent experience, training or coursework.(R)* Minimum three years of experience in a managed care setting, provider organization or health policy organization. (R)* Ability to build and maintain professional relationships with providers. Experience in relationship management and directing a coordinated response to complex problems (R)* Knowledge of Medi-Cal, Medicaid and/or Medicare managed care programs (D)* Ability to create and deliver effective presentations and communicate effectively while leading diverse groups. (R)* Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)* Proficient in adapting to changing situations and efficiently alternating focus to support department operations as dictated by business needs. (R)* Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)* Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, Powerpoint and Excel. (R)* Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)* Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)* Ability to maintain confidentiality. (R)* Ability to comply with all SCFHP policies and procedures. (R)* Ability to perform the job safely with respect to others, to property and to individual safety (R)
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
* Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)* Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)* Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)* Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)* Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)* Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.
Department: Provider Network Management
Reports To: Director, Provider Network Management or Operations Director, MLTSS
Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521
GENERAL DESCRIPTION OF POSITION
The Provider Network Associate will serve as a liaison to SCFHP's network of providers, hospitals, sub-acute facilities and health systems, including medical groups, independent clinics, mental health professionals, and ancillary providers. The Provider Network Associate will be an integral part of the Provider Network Management and MLTSS teams and will provide exemplary customer service and training to all providers in compliance with all applicable state and federal regulatory requirements, SCFHP policies and procedures, and business requirements.
ESSENTIAL DUTIES AND RESPONSIBILITIES
To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.
* Represent SCFHP in the provider community, including but not limited to, representing the department and SCFHP at internal and external meetings and events.* Via telephone and in person, act in the capacity of primary provider liaison and SCFHP subject matter expert by responding to and resolving complex provider questions and complaints/problems in an efficient and timely manner.* Assist providers to navigate SCFHP operations provider network systems, compliance and regulations.* Communicate clearly and concisely with providers at all levels, including administration, the business office and relevant vendors. Accurately capture and document issues and feedback. Convey information to other departments and organizational leadership when appropriate.* Collaborate with Provider Network Management and MLTSS team members to coordinate resolution of operational issues with internal departments and cross-departmental improvement efforts.* Assist with the development and monitoring of the provider network to identify issues related to network adequacy and/or access issues and take action, as needed to improve quality access to medical services and improve member satisfaction.* Create and deliver SCFHP provider orientation and training within established timeframes. On an annual basis, develop and execute provider communication plans including a schedule of site visits, trainings and meetings necessary to execute on the communication and training strategies.* Maintain knowledge of SCFHP's departmental functions and processes that enable research and identification of operational issues related to claims, authorizations, member grievances, provider disputes, and quality.* Build and maintain expertise and understanding of managed care, SCFHP policies and procedures and relevant regulatory requirements. Incorporate knowledge into the development of provider training and communication tools to improve compliance.* Create and participate in staff training. Assist with new hire training by allowing new Provider Services Representatives to shadow and observe performance and provide feedback to management.* Attend and actively participate in Provider Network Management and MLTSS meetings, other SCFHP operational meetings, training and coaching sessions, including off-site meetings as needed.* Initiate and manage process improvement projects in response to identified complex operational issues, trends or regulatory changes.* Perform other related duties as required or assigned.
REQUIREMENTS - Required (R) Desired (D)
The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
* Bachelor's Degree in Social Sciences, Business, or related field, or equivalent experience, training or coursework.(R)* Minimum three years of experience in a managed care setting, provider organization or health policy organization. (R)* Ability to build and maintain professional relationships with providers. Experience in relationship management and directing a coordinated response to complex problems (R)* Knowledge of Medi-Cal, Medicaid and/or Medicare managed care programs (D)* Ability to create and deliver effective presentations and communicate effectively while leading diverse groups. (R)* Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from offsite meetings or events; or ability to use other means of transportation to attend offsite meetings or events. (R)* Proficient in adapting to changing situations and efficiently alternating focus to support department operations as dictated by business needs. (R)* Ability to consistently meet accuracy and timeline requirements to maintain regulatory compliance. (R)* Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, Powerpoint and Excel. (R)* Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP internal departments, providers and outside entities over the telephone, in person or in writing. (R)* Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)* Ability to maintain confidentiality. (R)* Ability to comply with all SCFHP policies and procedures. (R)* Ability to perform the job safely with respect to others, to property and to individual safety (R)
WORKING CONDITIONS
Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.
PHYSICAL REQUIREMENTS
Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
* Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)* Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)* Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)* Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)* Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)* Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS
General office conditions. May be exposed to moderate noise levels.