Provider Relations Specialist V

In addition to the responsibilities listed below, this position is also responsible for leading the planning, development, and implementation of provider satisfaction strategies to improve network relationships and enhance provider engagement; overseeing the development of 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; leading the escalation of complex compliance issues to appropriate parties; supporting organizational responses to regulatory audits; and leading the delivery of provider education and/or onboarding.

Essential Responsibilities:

Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.

Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.

Supports continuous improvement efforts by: leveraging innovative and data-driven approaches to identify and/or consult on continuous improvement opportunities 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); driving the implementation of process improvement initiatives to aid providers and business goals; collaborating with internal and external partners to develop network strategies and implement improved access to care; and may also include conducting and/or collaborating in complex modeling and analyses of provider and market data to develop recommendations, solutions, and action plans for improvement initiatives.

Ensures contract commitments are met by: validating, maintaining, and/or conducting statistical analyses on provider and contract data of the day-to-day operation and management of services to identify trends and consult on provider compliance; documenting and reporting provider activities and/or coordinating with alternate stakeholders to ensure compliance with contract terms and conditions; promoting the use of 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 guiding corrective actions as identified through contract performance.

Supports contract strategy development by: developing, proposing, and implementing short-term strategies that improve access to patient care while managing outside service costs; providing in-depth and advanced consultation on local service delivery planning and delivery system leadership to aid in the achievement of provider priorities and strategies; may include leading 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).

Grows 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 using advanced knowledge of current service gaps; developing, maintaining, and managing trusted partnerships with providers to understand their unique service request needs and challenges; serving as a liaison between providers and KP by coordinating 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 aiding in developing itineraries and agendas, gathering credentialing materials, and/or initiating this process.

Contributes to provider satisfaction by: leveraging specialized knowledge of provider/contract operations to consult on issues that arise from contract configuration/interpretation and/or related to claims/disputes, billing, payment, reimbursement, directories, other operational issues, and/or directories; leveraging innovative solutions to ensure requests for information, questions, and problems are efficiently identified, documented, and addressed; and in some instances, collaborating on and acting as a role model in the creation and delivery of complex training materials to aid provider education and orientation on health plan systems, processes, and/or credentialing.