Facility: Health Plan

City San Diego

Department

Job Status

Regular

Shift

Day

FTE

1

Shift Start Time

Shift End Time

Driver's License - CA Department of Motor Vehicles; Bachelor's Degree

Hours :

Shift Start Time:

8 AM

Shift End Time:

5 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

No Weekends

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$33.090 - $42.697 - $52.303

The stated pay scale reflects the range that Sharp reasonably expects to pay for this position.  The actual pay rate and pay grade for this position will be dependent on a variety of factors, including an applicant’s years of experience, unique skills and abilities, education, alignment with similar internal candidates, marketplace factors, other requirements for the position, and employer business practices.

* Candidate must be located within San Diego or South Riverside counties. *

What You Will Do

Serves as the primary liaison between providers and the Plan, by establishing and maintaining positive working relationships through provider engagement and management. Develops and presents provider orientation/training and other resources to educate providers and key provider staff on Plan products, processes, and contract terms, both orally and in writing. Resolves provider inquiries and complaints in a timely manner using data analysis, critical thinking and dispute resolution techniques. Maintains continual contact with Plan providers and tracks provider interactions for reporting, trend analysis and follow-up purposes.

Required Qualifications

• Bachelor's Degree in Healthcare Management, Business, or other degree acceptable with combination of education and managed care experience.

• 3 Years experience in a managed care or healthcare environment interfacing with medical providers.

• Driver's License - CA Department of Motor Vehicles -REQUIRED

Preferred Qualifications

• Coursework in medical terminology and/or medical billing.

• Experience in sales and marketing with customer relationship responsibilities.

Essential Functions

• Provider RelationsMaintains close contact with Plan providers to stay up to date on their provider activities, program and initiatives for the Plan, including personal visits, written correspondence and phone contact.Drives operational efficiencies by resolving provider inquiries in a prompt and timely manner.Effectively conducts issue management and resolution using diplomacy and dispute resolution techniques.Leads customer relationship engagement activities such as education and committee initiatives.Employs focused and organized relationship management approaches to build and maintain strong relationships with Plan providers, and ensures that a high level of service and interaction is provided, including accurate and timely claims processing, issue resolution, performance recognition, education and training programs, and organizational support.Interacts effectively and professionally at different levels within and outside the organization for the purpose of developing and enhancing provider relationships.Maintains the provider operations manual, and provider communications to ensure compliance with regulations and contract requirements.Coordinates plan medical group and provider transitions and rollouts, including the facilitation of transition team meetings, and assistance with development of internal and external communications.Develops localized market expertise, including market issues, provider reputations, provider strengths and weaknesses, provider quality, availability, and referral source patterns, by establishing a personal presence in the market.Develops and executes action plans for the implementation of projects and provider communications, as needed.Recommends and/or drafts provider communications relative to health plan policies and procedures.Develops a communication plan for distribution of Plan policy changes and ensures that inventory of provider communication materials is maintained and tracked.Maintains a visitation and contact log to ensure thorough documentation of communication and follow-up.Ensures that contract is understood by the provider and that the provider is in compliance with contract.

• Training and EducationEducates Plan providers on Plan policies, procedures, contract terms, programs and initiatives through continual communications.Develops and implements an Orientation Program for all new providers who meet the credentialing requirements and who are recommended for acceptance by the Network/UM/Contracting Committee. The orientation should include a complete education regarding: a) Plan policies and procedures including authorizations and referrals, claims/encounters, provider utilization reports and grievance procedures; b) Rules, regulations, and other standards established by regulatory and accreditation agencies; and c) Training in the utilization of the SHP provider portal as a tool to enhance the provider’s practice efficiency.Develops presentations for orientations and on-going education, as needed.Educates providers on new protocols, policies, and procedures.Assesses training needs of physician office staff and PMG personnel. Develops, implements, and conducts appropriate training programs and on-going education initiatives for staff of assigned physicians, PMGs, hospitals and ancillary providers.Coordinates and oversees education and communication with providers related to quality improvement and outreach initiatives, including screenings, HEDIS, health fairs, disease management and other projects, as necessary.Coordinates the development and distribution of provider education information such as the Provider Operations Manual, provider alerts, and provider newsletters.

• RegulatoryCoordinates, facilitates and records Joint Operating Committee meetings at plan medical group office sites or virtually, and conducts physician, hospital and/or ancillary meetings, as necessary.Ensures provider network meets all regulatory and accreditation requirements including NCQA, DMHC and CMS.Keep abreast of the healthcare regulatory environment and regulatory changes to ensure the Plan maintains a compliant and adequate provider network.

• Network DevelopmentEvaluates the provider network to ensure appropriate access for membership using geo-access software applications, and recommends action plans, if necessary.Analyzes, interprets and communicates data related to provider performance in a clear, concise manner through routine reporting and presentations.Conducts external research to identify potential providers for the Sharp Health Plan provider network.Works closely with utilization management and contracting teams to ensure network gaps are identified and met.Makes recommendations and action plans to fulfill network development goals and eliminate deficiencies.Routinely monitors network changes and reports out on trends, critical issues and new developments to the Network Development and Application Optimization Manager.Effectively analyzes, synthesizes and graphically presents complex information and concepts in presentation, reporting and correspondence formats.Analyzes and interprets data to prepare accurate summary reports from provider research and findings.Facilitates the new provider contracting process to ensure that new providers meet all the credentialing and performance requirements of the Plan and their contract information is entered in the system timely and accurately.Manages provider demographic databases and ensures provider information and documentation is up-to-date, accurate, and complete for all providers, facilities, physicians, ancillaries and plan medical groups.Ensures that provider directory information is accurate, current and accessible when needed by internal and external parties.Participates in special projects and other duties, as assigned. These may include, but are not limited to, workgroups, proposals, audits and back-up support for other departments.

• Internal and External Customer ServiceProvides superior level of service to providers, responding to issues and problems in timely and thorough manner, as described in the Provider Operations Manual and all policies and procedures.Researches, analyzes and resolves, within limits of authority, issues related to contract interpretation, benefit and authorization inquiries, and operational issues; takes action to assure timely resolution of provider issues.Escalates recurring or critical issues, such as quality of care issues, claims payment issues, or access issues to the appropriate department in a timely fashion.Monitors provider complaints and makes recommendations to appropriate departments to address specific provider issues.Provides interpretation and clarification on provider’s contract, member benefits and member eligibility.Demonstrates ability to work through complex relationship issues, as evidenced by the successful development and execution of action plans to address specific performance issues.

• Project CoordinationManages, prioritizes, and completes multiple projects in a timely and accurate manner. Projects may include network development programs, provider research, provider education initiatives and provider onboarding programs.Develops project plans, production schedules and communication plans.Works closely with internal and external teams to gather accurate and timely information to ensure project plans are appropriate and up-to-date.Routinely monitors project status and maintains a cadence for status reporting.Creates monthly progress reports and communicates results to appropriate internal teams and management.Keeps and maintains project files.

• Quality and Process ImprovementMonitors the healthcare regulatory environment and reports out on future trends to appropriate staff and management.Identifies and facilitates opportunities to improve internal and external processes for provider management.Monitors and analyzes provider network performance trends and opportunities.Analyzes customer feedback and secondary research to identify opportunities for process and performance improvement.Conducts provider office site visits, as needed. Documents results and follow-up on corrective action plans, if necessary.Provides monthly reports of physician contact including encounters, site visits, and trainings.Conducts Provider Satisfaction Survey follow-up, as needed.Conducts Access and Availability Surveys and follow-up.Develops and implements action plans based on provider survey results, as needed.Develops and maintains processes for reporting and tracking provider feedback to other Plan departments.

Knowledge, Skills, and Abilities

• Proficient in the MS Office suite, including Word, Excel, PowerPoint, and Access required.

• Knowledge of customer relationship management, provider management, customer survey, project management, and credentialing software applications required.

• Ability to travel between Sharp Health Plan facilities, physician offices, hospitals / SNF’s and community resources, periodically outside of the San Diego area. Must provide own transportation with adequate insurance.

• Proficiency in Salesforce, Quest Analytics and MD-Staff preferred.

• Knowledge of regulatory, legal, and market trends relating to the regional healthcare industry and is able to apply knowledge as part of day-to-day job responsibilities.

• Knowledge of managed care principles, reimbursement methodologies, and healthcare delivery systems.

Sharp HealthCare is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, religion, color, national origin, gender, gender identity, sexual orientation, age, status as a protected veteran, among other things, or status as a qualified individual with disability or any other protected class