Provider Relations Rep – Orange, CA

This position is responsible for assisting with provider relations and service interactions to include but not limited to development and training of external provider education programs, identifying gaps in network composition and services and assists the network contracting staff in prioritizing contracting needs. The Provider Relations Representative assures that all provider orientations, site visits, access and availability studies are completed within established time frames. May be involved in identifying and remediating operational short-falls and researching and remediating claims.

Position Responsibilities:

  • Develops and manages relationships with providers.
  • Performs outreach, monitoring and resolution of operational and/or contractual issues.
  • Identifies network gaps and performs recruitment to address community network needs.
  • Completes new provider orientation for all applicable product lines within the CalOptima Community Network.
  • Conducts site visits to service providers, resolves issues, educates and interprets staff/providers on policies and procedures, collects credentialing information, and reviews HEDIS information.
  • Works with providers to adhere to contract, regulatory requirements and to communicate and meet the established CalOptima strategic goals.
  • Represents CalOptima at community and health plan-sponsored events.
  • Develops and delivers presentations on various CalOptima topics to the provider community.
  • Other duties as assigned.

Required Skills

  • Communicate effectively with providers both verbally and written.
  • Become familiar with CalOptima’s internal business systems (i.e. Facets, CCMS, etc.).
  • Plan and facilitate meetings.
  • Participate in audits and readiness assessments to assess contract compliance.
  • Coordinate and collate informational materials appropriate for the targeted audience.
  • Prioritize tasks in order to meet challenging deadlines.

Required Experience

Experience & Education:

  • Bachelor’s degree in Business Administration, Health Care Administration or other related field; or equivalent combination of education or experience required.
  • 2+ years’ experience in the health care field or managed care required.
  • Driver’s license and vehicle, or other approved means of transportation.

Knowledge of:

  • Principles and practices of Medi-Cal requirements.
  • Health care services delivery model (capitation vs. fee-for-service, staff physician models, Medicare, Medi-Cal, Cal MediConnect, commercial plans, etc.).
  • Guidelines and regulations specific to the health care field.
  • Claims and authorization processes (general knowledge).
  • Computers, keyboarding, software applications, e.g. Microsoft.

Grade: K


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