The Provider Relations Representative is responsible for addressing provider issues, applying resolutions, and responding to inquiries in an accurate and timely manner for both participating and non-participating providers. The Provider Relations Representative trains new and existing providers in accordance to Community Care Health (CCH) policies and procedures and completes provider on-site audits. Additionally, this position delivers provider relations support to internal departments, including but not limited to Contracting/Network Management, Quality, Compliance, and Medical Management. The provider representative also leads small projects for the department.

Key Responsibilities: 

• Field Liaison: Acting as the "go-between" for the health plan and providers. 

• Field Presence: Out of the office regularly, interfacing directly with the provider community. 

• Education: Meeting with office staff to teach them how to use the portal, check eligibility, and understand prior authorization policies. 

• Problem Resolution: Triaging provider issues (claims, authorizations, eligibility) and following through with internal departments (Claims, UM) until resolved. 

• Data Integrity: Working with Provider Network Ops to audit and update the provider directory. 

On-site (Base office at Shaw) when not traveling to providers offices. This position will have heavy field travel to provider offices.

Education

• High School Diploma, High School Equivalency (HSE), or Completion of a CHS Approved Individualized Education Plan (IEP) Certificate required
• Bachelor's Degree in Business or Healthcare Administration required
• Equivalent combination of education and experience may be substituted for the Bachelor’s Degree requirement

Experience

• 2 years of experience in managed care, physician office, or health plan environments required
• Health Plan experience is highly preferred to navigate internal issue resolution. 
• Local candidates are a major plus (those with existing local provider relationships). 
• Experience preferred for core systems: QNXT (will train), Word, and basic Excel (for tracking visits).  
• High-level presentation skills, patience, and strong listening/articulation abilities preferred.