Provider Relations Specialist IV

In addition to the responsibilities listed below, this position is also responsible for planning, developing, and implementing provider satisfaction strategies to improve network relationships and enhance provider engagement; developing provider relations programs to facilitate effective provider communications and problem resolution; and creating and distributing media materials (e.g., articles and newsletters), publications, and manual updates to providers; ensuring providers adhere to regulatory and contractual requirements; escalating complex compliance issues to appropriate parties; supporting organizational responses to regulatory audits; and delivering provider education and/or onboarding.

Essential Responsibilities:

Promotes learning in others by proactively providing and/or developing information, resources, advice, and expertise with coworkers and members; builds relationships with cross-functional/external stakeholders and customers. Listens to, seeks, and addresses performance feedback; proactively provides actionable feedback to others and to managers. Pursues self-development; creates and executes plans to capitalize on strengths and develop weaknesses; leads by influencing others through technical explanations and examples and provides options and recommendations. Adopts new responsibilities; adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; champions change and helps others adapt to new tasks and processes. Facilitates team collaboration to support a business outcome.

Completes work assignments autonomously and supports business-specific projects by applying expertise in subject area and business knowledge to generate creative solutions; encourages team members to adapt to and follow all procedures and policies. Collaborates cross-functionally and/or externally to achieve effective business decisions; provides recommendations and solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Supports the development of work plans to meet business priorities and deadlines; identifies resources to accomplish priorities and deadlines. Identifies, speaks up, and capitalizes on improvement opportunities across teams; uses influence to guide others and engages stakeholders to achieve appropriate solutions.

Supports continuous improvement efforts by: utilizing provider, claims, and contracting data to identify and/or consult on continuous improvement across the contract ecosystem (e.g., identifying business and operational disparities between organizational and provider expectations, constraints, and risks to accessible care, building and maintaining relationships); implementing process improvement initiatives to aid providers and business goals; participating in collaborations with internal and external partners to develop network strategies and implement improved access to care; and may also include conducting and/or collaborating on advanced modeling and analyses of provider and market data to develop recommendations, solutions, and action plans for improvement initiatives.

Ensures contract commitments are met by: gathering, validating, maintaining, summarizing, and/or analyzing provider and contract data of the day-to-day operation and management of services to consult on provider compliance; identifying and documenting provider activities and/or coordinating with alternate stakeholders to ensure compliance with contract terms and conditions; leveraging guidelines to ensure provider compliance with state and federal regulations as well as KP policies and procedures; and consulting with Provider Systems Administration (PSA) or its equivalent as needed to ensure proper contract interpretation and operational readiness and supporting corrective actions as identified through contract performance.

Supports contract strategy development by: researching, developing, and assisting in the proposal and implementation of strategies that improve access to patient care while managing outside service costs; providing advanced consultation on local service delivery planning and delivery system leadership to aid in the achievement of provider priorities and strategies; may include engaging in collaborative cross-functional workgroups to ensure provider strategies meet the unique needs of diverse stakeholders; and may also include developing materials and/or conducting peer training for new hires and contingent workers(e.g., establishing contract language, determining payment rate parameters, defining workflow and business processes, and ensuring cross-training across all service lines).

Supports the growth of the Provider Network by: reviewing or identifying recommended/potential partners/alliances for assigned service area to fill service gaps or decrease costs in current service offerings; developing and maintaining trusted partnerships with providers to understand their unique service request needs and challenges; serving as a liaison between providers and KP by contributing to communication efforts (e.g., contract compliance such as access, availability, referral operations, and/or supporting member complaints); and supporting provider site visits, daily interactions, and ad hoc meetings by partnering with others to develop itineraries and agendas, gather credentialing materials, and/or initiate this process.

Contributes to provider satisfaction by: leveraging in-depth knowledge of provider/contract operations to consult on issues that arise from contract configuration/interpretation and/or related to claims/disputes, billing, payment, reimbursement, other operational issues, and/or directories; ensuring requests for information, questions, and problems are identified, documented, and addressed in a timely manner; and in some instances, collaborating, creating, and/or delivering training materials to aid provider education and orientation on health plan systems, processes, and/or credentialing.