The Provider Services Representative – Hospital Relations is responsible for developing and maintaining strong and consistent relationships with IEHP hospital and ancillary Providers. Routinely communicate organizational policies, procedures and processes, regulatory updates. Anticipate and respond to Provider educational needs and conduct ongoing training. Integral to the implementation of improvement plans with , hospitals and ancillary providers in order to meet IEHP quality metrics, service goals and compliance standards. Major Functions (Duties and Responsibilities)
1. Conduct Provider orientation, continuous training and education to Providers and other stakeholders. Maintain accurate and timely log of Provider visits in compliance with NCQA standards, and DHCS and CMS regulatory requirements.
2. Act as a Provider Advocate and liaison between Providers and IEHP departments in resolving Member, Provider and other stakeholder issues and concerns.
3. As assigned, visit IEHP Providers on a periodic basis, focusing visits strategically under the direction of the Hospital Relations leadership team, in alignment with IEHP’s quality initiatives and strategic priorities.
4. Monitor Provider needs through utilization and other available reports, , quality data and cases . Support Providers through training and education to improve performance and satisfaction, close care gaps. and improve access to care.
5. Lead investigation and resolution of Provider grievances and health plan-related queries.
6. Promote Providers’ electronic submission capabilities including the timely and complete submission of encounter data, claims and utilization data related to IEHP’s quality metrics-.
7. Communicate with Provider staff regarding pertinent issues, quality initiatives plan changes and facilitate Member and Provider case resolution.
8. Maintain a strong partnership with the appropriate IEHP departments to ensure constant, timely internal communication and coordination to support – Providers in their day-to-day operations.
9. Attend internal meetings and participate in external Provider meetings and focus groups as appropriate.
10. Assist Providers with interpreting IEHP manuals and reports, including eligibility, capitation, claims data, and quality information.
11. Communicate changes regarding Provider information to ensure timely update of systems and directories.
12. Coordinate with appropriate departments to address Provider inquiries concerning rate/service changes and claims disputes.
13. Assist with the development of the Provider Policy and Procedure Manual as requested.
14. Assist with the development of written communication to the Provider network as requested.
15. Assist with Joint Operations Meetings (JOMs) as scheduled and as assigned.
16. As applicable, review and verify compliance of the appropriate networks, identifying gaps and requesting Provider response and submission of appropriate credentialing and related information to close network gaps and meet regulatory requirements.
17. Review and verify Provider directory information and lead investigation and resolution of reported Provider directory inaccuracies. Major Functions (Duties and Responsibilities) Cont Supervisory Responsibilities Leading: Self Experience Qualifications
Three (3) or more experience with customer service. One (1) year of experience including Hospital, Managed Care, Medical Group, IPA and HMO. Experience with managed care. Preferred Experience Education Qualifications
Bachelor’s degree from an accredited institution required. Preferred Education Professional Certification Professional Licenses Drivers License Required Yes, must have a valid California Driver’s license and valid automobile insurance. Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points. Knowledge Requirement
Working knowledge of Medical Group IPA and HMO operations. Working knowledge of hospital and ancillary provider operations preferred. Skills Requirement
Strong organizational skills. Excellent written and verbal communication and interpersonal skills. Microcomputer Applications (Microsoft Word and Excel, Access Preferred) for use in all aspects of an office environment. Skilled data input. Abilities Requirement
Possess telephone courtesy with a high level of patience. Excellent customer service skills. Commitment to Team Culture
The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization. Working Conditions
Data entry involving computer keyboard and screens, automobile travel within the IEHP service area, distribution of reports and supplies to outside Provider offices. Work Model Location Hybrid Physical Requirements Keyboarding: 10-Key – FREQUENTLY Keyboarding: Touch-Screen – FREQUENTLY Keyboarding: Traditional – FREQUENTLY Hearing: One-on-One – FREQUENTLY Near Visual Acuity – FREQUENTLY Sitting – CONSTANTLY Indoors – FREQUENTLY Lighting – CONSTANTLY Regular contacts: co-workers, supervisor – FREQUENTLY Memory – FREQUENTLY Understand and follow direction – FREQUENTLY Regular and reliable attendance – CONSTANTLY Use of computer mouse – FREQUENTLY Hearing: In a group – FREQUENTLY Hearing: Over the Telephone/Cell Phone – FREQUENTLY Hearing: Conference Speakers/Video Calls/Radio Calls – FREQUENTLY Alternate Sit/Stand or Walk at Will – FREQUENTLY Perform complex and varied tasks – FREQUENTLY Adaptability: rate of change in work tasks – FREQUENTLY Regular contacts: recurring clients – FREQUENTLY Rapid Pace of work – FREQUENTLY Pace of work with faster/slower work periods – FREQUENTLY Problem Solving – FREQUENTLY Communicate: Information/ideas verbally – CONSTANTLY Communicate: Verbally engage with customer base – CONSTANTLY Develop and maintain positive work relationships – CONSTANTLY
Starting Salary: $61,422.40 – $78,312.00
Pay rate will commensurate with experience
Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 7,000 and a team of more than 2,500 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.