POSITION SUMMARY

The Representative I, Provider Relations, is a member of a cohesive unit that responds to and provides education to providers regarding Gold Coast Health Plan and its health care programs. The Representative I, Provider Relations, will directly represent Gold Coast Health Plan and will focus on maintaining a positive presence in the community.

ESSENTIAL FUNCTIONS

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 Statement(s)

• Lead face-to-face educational visits with physicians and their office staff to educate them on other Gold Coast Health Plan policy and procedures.
• Be able to answer many claims submission questions and have a good understanding of physician claims processing.
• Act as a liaison between Gold Coast Health Plan and the provider community to effectively resolve provider issues, address concerns and resolve problems.
• Reach out telephonically to physicians and their staffs to follow up on information needed by Gold Coast Health Plan.
• Be familiar with Gold Coast Health Plan's contract requirements for PCPs and Specialists.
• Coordinate and conduct regularly scheduled meetings with providers and follow-up on outstanding issues.
• Work with providers to adhere to contract and regulatory requirements.
• Respond to provider requests, inquiries, and needs in a timely manner.
• Initiate face-to-face visits with the provider and office staff at the provider's location in order to respond to the individual provider needs.
• Research and resolve claims and authorization issues and/or elevate to other Plan management.
• Develop and deliver presentations on various business topics to the provider community.
• Projects assigned by the management that involve the Provider Relations Department.
• Other duties as assigned by management. POSITION QUALIFICATIONS Competency Statement(s)
• Management Skills - Ability to organize and direct oneself and effectively supervise others.
• Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.
• Customer Oriented - Ability to take care of the customers’ 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.

SKILLS & ABILITIES

Education: Bachelor's Degree (four year college or technical school) Preferred, Field of Study: Business Administration, Health Care Administration or other related field preferred.

Experience: 4 plus years of experience in the health care field interacting directly with providers. irect experience with physician offices and be familiar with physician claims related issues.

Computer Skills: Advanced computer skills included in the MS Office products.

Certifications & Licenses: A valid California Driver's License and insurance

Other Requirements: Act as a liaison between the provider and Gold Coast Health Plan. Must be able to work the internal and external systems in order to achieve the desired result.

Be familiar with claims related issues and be able to help resolve them.

Be familiar with and able to interpret policy and procedures and various contracts. Respond appropriately to provider inquires in order to alleviate confusion or frustration. Become familiar with IKA internal business systems.

Participate in audits and readiness assessments to assess contract compliance. Prioritize tasks in order to meet challenging deadlines.