Provider Relations Rep

Job Summary

This position supports the department leadership in the overall management of the TriWest provider networks. Ensures high level of customer satisfaction by serving as the consulting resource for the Provider Services Department and TriWest. Serves as the subject matter expert by educating providers on TriWest provider agreements, reimbursement methodologies, provider education content, contract requirements, and new programs. Facilitates research, resolution, and tracking of escalated provider issues. This position must keep current and follow VA, TRICARE, TriWest, and departmental policies and procedures and submit reports in a timely manner. Assigned territory may cover four to nine states in the designated VA Region.

Education & Experience

Required:

• Bachelor's (BA/BS) Degree in health care or related field or equivalent experience
• If supporting TRICARE contract, U. S. Citizenship
• If supporting TRICARE contract, must be able to receive a favorable interim and adjudicated final Department of Defense (DoD) background investigation
• 3 years managed health care experience (provider relations and/or provider education) or experience working for a health care provider, with increasing responsibility
• Provider contracting experience
• Ability to work in a highly matrixed environment
• Ability to work in a fast-paced environment and triage constantly changing priorities

Preferred:

• Experience processing referrals/authorizations or claims or handling escalated provider issues to resolution
• Experience with healthcare-related electronic transactions and reimbursement methodologies
• Experience in leading and facilitating meetings

Key Responsibilities

• Document and follow-up on access to care issues. Monitor the network to ensure appropriate action to eliminate network shortfalls.
• Establish and maintain positive working relationships with both internal and external customers. Responding to emails, phone calls, customer service inquires by fully researching inquiry and responding timely.
• Subject matter expert of VA and TRICARE payment methodologies and TriWest policies and procedures for the administration of the VA and TRICARE Programs.
• Coordinate and ensure timely provider contracting and re-contracting projects.
• Issue management and resolution of escalated issues; resolving provider issues in collaboration with Claims and Operations departments and reporting updates to Leadership.
• Maintains professional working relationship with other TriWest departments, and stays abreast of provider educational needs.
• Remains current on all VA, TRICARE, TriWest and departmental policies and procedures by taking all available training and reviewing e-mail, TriNet, and www.triwest.com communications.
• Recommends future provider educational needs based on observations of and discussions with providers and provider questions during live and web-based training.
• Provides feedback to management of any claims processing, referral/authorization, or other unfavorable trends from provider interactions.
• Actively promotes electronic claims submission & secure website functionality in all provider interactions.
• Maintains accurate provider contact records in the contact management system.
• Reviews and submits feedback timely on draft provider educational materials.
• Assists/participates in projects as assigned by Manager.
• Performs other duties as assigned.
• Regular and reliable attendance is required.

Competencies

Communication / People Skills: Ability to influence or persuade others under positive or negative circumstances; adapt to different styles; listen critically; collaborate.

Computer Literacy: Ability to function in a multi-system Microsoft environment using Word, Outlook, TriWest Intranet, the Internet, and department software applications.

Independent Thinking / Self-Initiative: Critical thinkers with ability to focus on things which matter most to achieving outcomes; commitment to task to produce outcomes without direction and to find necessary resources.

Information Management: Ability to manage large amounts of complex information easily, communicate clearly, and draw sound conclusions.

Multi-Tasking / Time Management: Prioritize and manage actions to meet changing deadlines and requirements within a high volume, high stress environment.

Problem Solving / Analysis: Ability to solve problems through systematic analysis of processes with sound judgment; has a realistic understanding of relevant issues.

Technical Skills: The ability to solve problems independently while working in a fast paced, energetic environment; strong communication skills, (oral and writing skills); a proven ability as a facilitator/instructor; self-motivated, able to work in a team and independently.

Working Conditions

Working Conditions:

• Favorable working conditions in a climate-controlled office space
• Must be able to travel (locally or distant with overnight stays) a minimum of 25% and maximum of 75% of the time
• Must be able to lift a minimum of 20 lbs. of equipment and course material
• Must be able to work under stressful conditions