Title Senior Provider Relations Representative
Posted Date 05/10/2017
Employer Health Net
Job Information


JOB FAMILY: Provider Services BAND: HZI


JOB Summary:

Under direction, the Senior Provider Relations Representative Multiple LOB maintains working relationships with provider organizations as assigned. This position is responsible for assuring accurate provider data, monitoring accounts receivable, and providing training, education, and information to providers. Acts as the Company liaison to providers, communicating Health Net’s policies and procedures. May provide guidance or expertise to less experienced associates. Assesses provider-training needs. Assures compliance with contracts.  Works with providers and internal departments to improve STAR rating, NCQA, HEDIS scores, encounter submissions, and other measures as required.

essentIaL duties and responsibilities:

Assures compliance with respective contracts. Researches, analyzes and resolves claims, benefits, issues and authorization inquiries within delegated authority.

Interprets Health Net’s policies and procedures. Provides interpretation and clarification of benefits, eligibility, and access to care requirements. Escalates recurring or critical issues as appropriate to management. Acts as a conduit for resolution with Provider Network Management.

Assesses provider-training needs. Develops, implements, and conducts appropriate training programs and/or orientations for assigned provider staff.

Educates/trains providers and provider office staff about regulatory requirements including CMS/DMHC/DHCS.

Influences membership growth and retention through the provider offices.

Monitors provider database of current data relating to provider and physician information.

Ensures provider directories are accurate.

Investigates compliance issues, identifies root cause, trains provider office staff on correct procedures, and provides written report of findings and recommendations.

Meets on a regular basis in person or by telephone with assigned key provider groups to cultivate and strengthen relationships. Documents office visits and provider issues on shared drive log.

Supports the retention of providers by participating in meetings, conducting research, and supporting provider credentialing.

Assists management in tracking, trending and reporting on provider recruitment and retention.

Provides support on special projects and performs other duties as needed or assigned.

education/experience/minimum requiremenTs:


Bachelor’s Degree in Health Care Administration or related field preferred





Minimum three years’ experience in provider relations, health plan operations or health care/medical office environment


Knowledge, Skills & Abilities:

Thorough understanding of State Medical Assistance Program, Health Plan products and lines of business, as well as familiarity with claims pricing and reimbursement strategies

Must be accurate and detail oriented

Must have strong oral and written communication skills and presentation skills to communicate with and engage providers and provider office staff

Proficient with Microsoft Office (Word, PowerPoint and Excel)

Possess knowledge of state and federal health care regulations, coding, medical terminology, claims processing and provider billing

Knowledge of State and Federal regulations as they apply to managed care principles and provider practice guidelines

Strong influence skills to change behaviors

Ability to travel throughout the state required



The following section describes the general physical requirements for this position.  Please note that ‘constant’ refers to more than 81% of time; ‘significant‘ refers to 40-80%; and ‘moderate’ refers to 20-40% of the time.

Operates personal computers, printers, facsimile, telephones, copy machines and other commonly used office accessories/equipment.

Exposed to confidential information and expected to maintain confidentiality at all times; must adhere to HIPAA rules and regulations.

May be required to work outside of normally scheduled hours as mandated by the client, project and/or workload (e.g. evenings, weekends, and/or holidays).

May be required to maintain established work pace, meet deadlines; may have last minute urgent requests.

Physical activity may include: twisting, reaching, kneeling, bending, stooping, squatting, crawling, grasping, grabbing, pushing, pulling, repetitive motion, climbing, etc.

Required to have visual acuity to determine the accuracy, neatness, and thoroughness of the work assigned.

Required to have hearing ability to receive detailed information through oral communication.

Required to have speaking ability to express or exchange ideas.

Constant concentration may be required on various subjects by listening, reading and thinking clearly.

Interaction with others may be required.  May need to listen, think, and speak in order to interact with others. Business interactions and behavior between coworkers and/or external customers are required.  This may require face-to-face or telephone interactions.

Thinking at work may include listening, learning, analyzing, evaluating, and the ability to interpret what is seen and/or heard, or to link information from one issue to the next.

Constant computer usage including typing and/or eye strain.

Constant repetitive arm, wrist, hand and finger motions — making repetitive movements (e.g. key boarding, filing, data entry).

Significant phone usage; headsets may be required.

Significant amount of time spent working in a loud office environment with frequent interruptions/distractions.

Constant sedentary work (desk bound or seated).

Constant reading is required via computer screen and/or bound printed materials.

Moderate walking/standing may be required.  Walking and/or transporting supplies and equipment between buildings/parking lots and structures may be required.


Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position.

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