Provider Relations Representative

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Job Summary

The Provider Relations Representative at Healthy Partners will play a crucial role in managing relationships between our Management Services Organization (MSO) and our network of affiliate providers, as well as liaising with HMO payors. This role involves addressing provider issues, enhancing provider satisfaction, and supporting quality improvement initiatives related to KPIs, Medical Loss Ratio (MLR), and HEDIS measures. The ideal candidate will have a strong understanding of MSO operations, experience in HMO payor relationships, and a focus on improving provider performance and operational efficiency.

Essential Duties & Responsibilities

Provider Relationship Management: Serve as the primary point of contact for providers, addressing concerns and resolving issues effectively and efficiently. Develop and maintain strong relationships with healthcare providers to boost satisfaction and engagement. Regularly engage with providers to collect feedback and address operational challenges. Operational Support: Oversee the onboarding and contracting processes for new providers, ensuring compliance with organizational standards and regulatory requirements. Manage provider data and information within MSO systems, ensuring accuracy and consistency. Ensure all provider interactions adhere to MSO policies and procedures. Performance Monitoring and Improvement: Monitor and analyze provider performance metrics, including KPIs, to identify trends and areas needing improvement. Develop and implement strategies to enhance provider performance and achieve MSO objectives. Collaborate with internal teams to address performance issues and drive continuous improvement initiatives. Quality and Compliance: Support initiatives to improve the Medical Loss Ratio (MLR) by working with providers to enhance cost-effectiveness and quality of care. Monitor and contribute to achieving HEDIS measures and other quality metrics. Ensure compliance with relevant regulations and standards, including those related to HEDIS reporting and quality improvement. HMO Payor Relationship Liaison: Act as a liaison between the MSO and HMO payors, ensuring smooth communication and coordination of efforts. Manage and strengthen relationships with HMO payor representatives to address issues, negotiate terms, and support collaborative initiatives. Work with HMO payors to align policies and practices with MSO objectives and provider needs. Strategic Planning and Collaboration: Work closely with internal teams to align provider relations strategies with organizational goals and MSO objectives. Provide insights and recommendations based on provider feedback and performance data to support strategic decision-making. Participate in cross-functional teams to drive projects and initiatives related to provider relations and performance improvement.

Supervisory Responsibilities

No supervisory responsibilities.

Education & Experience

Bachelor’s degree in Business Administration, Healthcare Management, or a related field; advanced degree, preferred. Proven experience (3+ years) in provider relations or network management within an MSO or similar healthcare setting. Strong understanding of MSO operations, healthcare provider networks, and industry regulations. Experience in managing HMO payor relationships and familiarity with HMO payor processes. Knowledge of Medical Loss Ratio (MLR) and HEDIS measures, and experience in performance monitoring and improvement. Excellent communication, negotiation, and problem-solving skills. Ability to analyze data, identify trends, and develop actionable strategies. Proficiency in MS Office Suite and familiarity with EMR systems.

Education Requirements

Education Level

Discipline

Required

Bachelor's Degree

Business Administration, Healthcare Management, or a related field

Knowledge, Skills & Proficiencies

Ability to perform complex problem solving Ability to work effectively with physicians Knowledge of HMO and MSO operations, and continuous quality and utilization/medical management techniques and operations Strong people and project management skills Demonstrated ability to develop and implement new business units and service lines Knowledge of Disease Management implementation models Comfort in Computer applications Project Management skills and experience are preferred Limited knowledge of medical terminology is preferred Fluent in English and Spanish

Physical Requirements

This position works under usual office conditions. The associate is required to work at a personal computer as well as be on the phone for extended periods of time. Must be able to stand, sit, walk and occasionally climb. The incumbent must be able to work extended and flexible hours and weekends as needed. Physical demands include ability to lift up to 50 lbs. The physical demands described here are representative of those that must be met by an associate to successfully perform the essential functions of the job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Work Conditions

Must be able to perform essential functions such as typing, standing, sitting, stooping, and occasionally climbing.

Travel Requirements

Amount of Expected Travel

Details

Yes

0-25%

Flexibility to travel to clinical sites as needed

Tools & Equipment Used

Computer and peripherals, standard and customized software applications and tools, and usual office equipment.

Disclaimer

The duties and responsibilities described above are designed to indicate the general nature and level of work performed by associates within this classification. It is not designed to contain, or be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications required of associates assigned to this job. This is not an all-inclusive job description; therefore, management has the right to assign or reassign schedules, duties, and responsibilities to this job at any time. Cano Health is an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to sex, gender identity, sexual orientation, race, color, religion, national origin, disability, protected veteran status, age, or any other characteristic protected by law.

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