JOB SUMMARY:

The Senior Provider Relations Representative is office-based and is responsible for resolving Physician, Hospital, Ancillary, and Physician organization (Provider) focused issues including, but not limited to educational needs, contract verification, participation status, claims payment discrepancies, interaction with Community's provider portal, and questions regarding Community's process for obtaining authorizations.

The Senior Provider Relations Representative exhibits good communication and interpersonal skills; maintains a working knowledge of the designated QNXT referral, claims, eligibility, and provider modules, as well as all CACTUS modules, and serves as the primary party responsible for responding to inquiries referred to Provider Relations.

The Senior Provider Relations Representative ensures that new Providers receive the required initial education materials, i.e., Provider Manual, Quick Reference Guides, etc.; supports the Provider Engagement Representatives and Provider Relations Representatives by monitoring and reporting educational needs identified through web inquiries, reports, and other analytical measures; may provide guidance or expertise to fellow team members.

Works closely with management or takes the lead to create, maintain and update provider communications including, but not limited to provider notices, provider manuals, quick reference guides, and orientations as required by URAC, NCQA, TDI, HHSC, CMS, and other regulatory agencies.

Collaborates with leadership, co-workers, and staff in other departments to achieve departmental and organizational objectives.

MINIMUM QUALIFICATIONS:

Education/Specialized Training/Licensure:

• High School or equivalent required. BA/BS in Business preferred

Work Experience (Years and Area):

• 5 years experience in managed care (Provider Relations/Services; Claims Adjudication, Medical Coding, Contracting)

Software Operated:

• Microsoft Office (Word, Excel, Outlook and PowerPoint),
• QNXT and CACTUS systems preferred

SPECIAL REQUIREMENTS:

Communication Skills:

• Above Average Verbal (Heavy Public Contact)
• Writing /Composing: Correspondence / Reports

Other Skills:

• Medical Terminology, Statistical, MS Word, MS Excel, MS PowerPoint

Advanced Education:

• Bachelor's Degree Major: Preferred

RESPONSIBLE TO: Director

EMPLOYEE SUPERVISED: None