Responsible for managing assigned territory of professional, institutional and ancillary provider types in order to enhance these relationships so that BMCHP becomes their plan of choice.  Serves as the primary liaison between BMCHP (“Plan”) and key provider organizations, taking the lead and promoting collaboration within Plan, as it relates to provider network maintenance.  Manages territory inclusive of one or more of highest priority network partnerships, as well as multiple other providers, facilities and community health centers.  Works closely with the Provider Relations Manager to identify issues and report trends.  Acts as liaison between provider and internal Plan departments such as Provider Enrollment, Claims, Audit, Marketing, Customer Care and Care Management.

KEY FUNCTIONS/RESPONSIBILITIES:

• Develops and enhances our physician, clinician, community health center and hospital relationships through effective business interactions and outreach.
• Works collaboratively with Provider Relations Consultants and Manager to develop  and update provider orientation programs.
• Coaches and assists in the training of Provider Relations Consultants and Provider Relations Specialists.
• Organizes, prepares and conducts orientations of network providers (administrative and clinical) and their staff. Takes the lead on specific Plan initiatives as they relate to provider education.  Provides general instruction and support on BMCHP products and policies to providers and coordinates office and provider site clinical and administrative meetings.
• Meets with assigned providers regularly according to pre-set site visit servicing standards.  Documents all pertinent provider communications and meetings in Onyx.
• Acts as liaison for all reimbursement, credentialing, claims, EDI web site procedures and issues of key providers.  Facilitates resolution of complex contractual and member/provider issues, collaborating with internal departments as necessary.
• Works collaboratively with Contract Managers in implementing and administering contractual provisions of provider agreement to ensure contractual compliance.  Monitors contractual compliance on an on-going basis.
• Manages the implementation of new provider contracts, assisting when needed, so providers can be credentialed, loaded in systems and notified within standards set by department. 
• Manages flow of information to and from provider offices.  Monitors and communicates market trends and issues.
• Outreaches to providers according to Plan initiatives.
• Analyzes operational issues with regard to territory and provider operations such that interrelationships among other area providers are considered.
• Facilitates timely problem resolution.  Initiates Plan interdepartmental collaboration to resolve complex provider issues.
• Identifies system updates needed and completes research related to provider data in Onyx and Facets.
• Represents Provider Relations and the plan at external provider and community events to maintain visible presence.
• Processes reports as needed to support provider education, servicing, credentialing and recruitment.
• Assists in developing marketing materials.  Participates in community outreach activities and events.
• Ensures quality and compliance with state Medicaid regulations and NCQA requirements. 
• Other responsibilities as assigned.

QUALIFICATIONS:

EDUCATION:

• BA/BS required or  related field, or an equivalent combination of education, training and experience

EXPERIENCE:

• 4 or more year’s progressively responsible experience in provider relations or network management required
• Experience in the Medicare provider healthcare insurance industry preferred

CERTIFICATION OR CONDITIONS OF EMPLOYMENT:

• Must have valid driver’s license and access to reliable transportation

COMPETENCIES, SKILLS, AND ATTRIBUTES:

• Knowledge or familiarity with Medicaid and Medicare is a plus
• Understanding of the local provider community
• Proven demonstration of effective communication skills (verbal and written), and interpersonal skills
• Demonstrated ability to establish, build and maintain relationships with internal and external constituents
• Strong analytical, research and organizational skills
• Strong follow up skills
• Ability to think and react quickly to address questions and issues while interacting with the provider community
• Foster an atmosphere of collaboration and teamwork internally and externally
• Demonstrate initiative, judgment, discretion and ability to operate within politically sensitive framework
• Ability to be flexible, work independently and manage multiple tasks
• Demonstrated competence using Microsoft Office products especially Excel and Access; familiarity with FACETS helpful
• Demonstrated competence using Microsoft Office products especially Word, Excel, Outlook, Access, PowerPoint.  Experience or knowledge of FACETS

WORKING CONDITIONS AND PHYSICAL EFFORT:

• Must be willing to travel significantly to local communities to meet business needs up to 75% of time

*Qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, sexual orientation, gender identity, disability or protected veteran status.

Required Skills Required Experience