You Make Us Grow. You Make Us Sharp.

Hours:

Shift Start Time:

8 AM

Shift End Time:

5 PM

AWS Hours Requirement:

8/40 - 8 Hour Shift

Additional Shift Information:

Weekend Requirements:

Not Specified

On-Call Required:

No

Hourly Pay Range (Minimum - Midpoint - Maximum):

$36.830 - $47.530 - $53.230

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.

Please Note: As part of our recruitment process, you may receive communication from Dawn, our virtual recruiting assistant. Dawn helps coordinate scheduling for screening calls and interviews to ensure a smooth and timely experience. Rest assured, all candidate evaluations and hiring decisions are made by our recruitment and hiring teams.

What You Will Do
Serves as a primary liaison between healthcare providers and the Sharp Health Plan to engage, educate, and serve the needs of the Plan's provider network through dedicated coordination and partnership. Performs an integral role in provider relations, network compliance and network development. Develops dashboards and reports to monitor and evaluate provider interactions for trend analyses, reporting, and follow-up purposes. Resolves complex, high-priority provider inquiries and complaints in a timely manner. Takes initiative in preventing and resolving issues between the provider and the Plan. Responsible for the Plan's provider orientation/training program, including the writing and development of presentations, and other resources to educate providers and provider staff on Plan products, processes, and contract terms. Performs a key role in content development and provider relationship building for joint operating committee meetings with delegated medical groups.

Required Qualifications

• Bachelor's Degree in Healthcare Management, Business, Communications, or related field of study.
• 5 Years Experience in healthcare or managed care to include provider services, healthcare administration, health plans and/or claims experience.
• 2 Years Experience with customer relationships or account management.
• Driver's License - CA Department of Motor Vehicles -REQUIRED

Other Qualification Requirements

• Utilizes reliable transportation and possesses adequate personal insurance coverage. Demonstrates clean driving record in accordance with requirements of the employer DMV pull notice program and Sharp HealthCare Driver Guidelines.

Essential Functions

• Provider Relations and Communications
  Builds and maintains a professional relationship with Plan providers across all lines of commercial and Medicare business (HMO, PPO, HAS, POS, Medicare Advantage) to stay up-to-date on their provider activities, programs, and initiatives for the Plan via multiple channels including site visits.
  Tracks, monitors, and trends KPIs and key metrics for provider account management and network compliance. Prepares summary reporting and presentations for Director and senior leadership.
  Builds and maintains internal and external communications calendars as well as dashboards for projects and functional reporting.
  Leads customer relationship engagement activities such as education and committee initiatives.
  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.
  Processes and documents provider inquiries and interactions across multiple channels, including virtual and in-person meetings and site visits.
  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.
  Effectively conducts complex and sensitive issue management and resolution using diplomacy and dispute resolution techniques.
  Coordinates, writes, and disseminates provider communications to ensure provider awareness of Plan programs, contract requirements, and compliance with federal and state regulations.
  Maintains a contact log to ensure thorough documentation of provider communications and follow-up, and creates new trackers, as needed.
  Creates and maintains dashboards and processes for tracking on provider encounters, provider portal registrations, site visits, trainings, provider feedback etc. Provides reports and analysis/trends to leadership.
  Review and comprehend provider contracts in order to respond to inquiries from physicians and staff. Conducts contract analysis related to contract performance by examining appropriate claims and other applicable data.
  Ensures that contract is understood by the provider and that the provider is in compliance with contract.
  Attends internal and external meetings as a departmental representative or to educate providers and stakeholders on Plan policies, procedures, legislation, standards, provider tools and resources, including writing meeting agendas, meeting facilitation, as needed, and writing and distributing meeting minutes.
  Assists internal teams in the development of sales and marketing materials with provider information and resources for use at broker and employer group health fairs and open enrollment events.
  Train and guide other Provider Account Representatives on department processes and procedures, building relationships, etc.
  Participates in special projects and other duties, as assigned.
• Provider Training and Education
  Develops and implements a Provider Education Program for new and existing providers, including: a) Plan policies and procedures, administrative cost effectiveness, member satisfaction, regulatory programs, health plan quality programs, health plan digital solutions, 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 provider portal and other resources as tools to enhance the providers practice efficiency.
  Tracks, measures and evaluates effectiveness of Provider Education Program Evaluate through methods such as pre- and post-training assessments, provider feedback surveys, observational assessments, and by monitoring Key Performance Indicators (KPIs).
  Assesses training needs of providers and provider office staff, and develops presentations for orientations and ongoing education, as needed.
  Develops comprehensive communications plans for ongoing provider education, onboarding, and other Plan initiatives.
  Produces, updates and distributes educational presentations and information for ongoing provider education.
  Leads provider onboarding and education to ensure smooth transitions for new provider groups.
  Conducts virtual as well as on- and off-site training sessions for new and existing providers and provider office staff, including delegated medical groups, independent providers, hospitals, facilities, and ancillary providers.
  Schedules and performs the dissemination of provider education information such as the Provider Operations Manual, provider alerts, and provider newsletter across multiple channels.
  Trains providers in the utilization of the SHP provider portal as a tool to enhance the provider’s practice efficiency. Acts as a liaison between providers and internal IT teams.
• Network Compliance/Regulatory
  Keeps abreast of the healthcare regulatory environment and regulatory changes to ensure the Plan maintains a compliant and adequate provider network.
  Produces and validates report submissions for regulatory filings with various state and federal agencies and accreditors. Activities may include provider outreach, data collection, network development, surveys, and other activities to meet filing requirements.
  Leads annual and ad hoc updates and dissemination of the Provider Operations Manual, including the development and writing of new content and coordination with all Plan departments. Creates, maintains, and executes document production schedule, and ensures that regulated deadlines for dissemination are met.
  Ensures providers meet all federal and state regulatory and accreditation requirements, including but not limited to, the DMHC, CMS, Covered CA and NCQA via monitoring, communication, site visits, and corrective action, as needed.
  Conducts committee meeting administration and facilitation for the Joint Operating Committee meetings for delegated medical groups, including annual calendar maintenance; creates, updates, and maintains production schedules; scheduling of committee and follow up meetings; new content development for presentations; writing and distribution of meeting minutes; and related follow-up activities. Conducts outreach and schedules meetings with provider groups, hospitals, and service ancillary providers, as needed.
  Manages vendor and conducts outreach and follow-up for annual timely access provider surveys. Execute tasks based on action plans to improve timely access provider survey results, as needed. Documents results and follow-up for provider notices of non-compliance and corrective action plans, as needed.
  Develops and implements action plans for provider performance improvement based on annual timely access provider survey results, as needed.
  Designs and conducts other provider surveys for network management, as needed.
  Updates and maintains the Provider Account Representative Guide on department processes, procedures, and contacts.
  Keeps and maintains trackers and project files for audit purposes.
  Consistently provides audit support through routine maintenance and appropriate storing of regulated documentation.
• Network Development
  Makes recommendations and action plans to fulfill network development goals and eliminate deficiencies, working closely with Compliance and other internal teams.
  Routinely monitors network changes and reports out on trends, critical issues, and new developments.
  Conducts external research to identify potential providers for the Sharp Health Plan provider network.
  Researches, writes, and presents provider profiles for network consideration.
  Coordinates, schedules, presents, writes/distributes meeting minutes at internal network development meetings.
  Maintains forms and trackers for new provider requests, and processes requests in a timely manner.
  Works closely with utilization management and contracting teams to ensure network gaps are identified and met.
  Liaises with Contracting team to facilitate the contracting process.

Knowledge, Skills, and Abilities

• Knowledge of managed care principles, reimbursement methodologies, and healthcare delivery systems.
• Consistently exercises good judgement and possesses strong diplomacy and relationship-building skills.
• Must possess excellent organizational skills with the ability to prioritize work to meet critical deadlines.
• Ability to work comfortably in a fast-paced work environment and effectively manage multiple priorities.
• Excellent skills in the MS Office suite, including Word, Excel, PowerPoint, required.
• Proficiency in Epic, Smartsheet, Salesforce, and MD-Staff or similar applications required.
• 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.
• 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.
• Ability to read and analyze, and interpret contracts, general business periodicals, professional journals, technical procedures, or governmental regulations.
• Ability to write reports, business correspondence, and procedure manuals in a professional and accurate manner with a strong foundation in document management and version control.
• Ability to effectively present information and respond to questions from groups of managers, providers and the general public.
• Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
• Ability to interpret and conduct a variety of instructions furnished in written, oral, diagram, or schedule form.
• Ability to understand and train in the use of software applications aimed at health plans and provider groups such as portals, claims, and practice management systems.
• Requires up to 15% travel among Sharp Health Plan facilities, physician offices, hospitals, service ancillary providers, facilities, and community resources in the San Diego and South Riverside Counties. Must provide own transportation with adequate insurance.

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

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