Why This Role is Important to Us:

The Provider Relations Specialist is responsible for cultivating, maintaining and strengthening relationships with the Commonwealth Care Alliance’s (CCA) provider community. In this highly visible field position, the provider relations specialist acts as the primary liaison between CCA and its providers including primary care practices, specialists, physician organizations, hospitals, ancillary and LTSS providers. Key responsibilities include establishing positive working relationships with providers, effectively communicating with and educating those providers about CCA and resolving provider inquiries.

What You'll Be Doing:

• Develop strong professional relationships with all providers and their staff while functioning as a liaison to the provider community to research and resolve complex provider issues.

• Take ownership of the provider relationship, ensuring all provider needs and concerns are addressed and answered.

• Facilitate and lead orientation meetings and communication sessions with key providers; orient providers on CCA’s policies related to:

• Claims and service recovery

• Program benefits

• Clinical initiatives

• Referral and authorization

• Regulatory compliance

• Billing and payments

• Complaints and appeals

• Policies and procedures

• Identify opportunities for training and education.

• Manage and respond to a high volume of provider inquiries while ensuring consistent follow through on resolution of issues.

• Represent CCA at provider related events and other initiatives, as necessary.

• Prioritize and organize own work to meet deadlines.

• Work collaboratively with Provider Network Management staff to ensure an adequate and appropriate provider network. Participate in contracting strategy discussions around potential recruitment opportunities.

• Coordinate with other CCA departments, including Clinical Management, Member Services, Regulatory Affairs, Claims and Outreach and Marketing, to resolve provider issues.

• Participate in departmental and interdepartmental meetings as appropriate and necessary

• Participate in the development of departmental policies, procedures and processes.

• Special projects as assigned or directed.

• Maintain professional growth and development.

What We're Looking For:

• Bachelor’s degree preferred or equivalent work experience

• 3-5 years of experience

• Managed Care experience (preferably Medicare/Medicaid).

• Experience in health plan provider relations.

• Understanding of provider office operations as they relate to health plans

• Knowledge of billing practices and reimbursement methodologies.

• Excellent verbal, written and presentation skills.

• Outstanding Customer Service Skills.

• Intermediate Microsoft Office competency, including Outlook, Word, Excel & Power Point.

• Ability to multi-task.

• Ability to work independently.

• Ability to interact well with individuals on all levels, and maintain a professional image and attitude.

• Strong analytical, problem solving and project management skills.

• Detail oriented, with the ability to organize and manage multiple priorities.

• Experience with CPT coding and authorization process highly desired.

• Experience with and understanding of Claims operations preferred

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.