Location: Atlanta Office (211 Perimeter Ctr. Parkway, Suite 800, Atlanta, GA 30346)
Reports To: Manager, Provider Relations
Department: Provider Relations
Manages provider Network performance for assigned territory with an account management approach. Achieves market performance targets through the implementation and execution of Network transformation strategies in order to improve overall Network performance.
Owns and manages contractual relationship and performance of assigned in-network provider groups. Serves as primary point of contact for assigned providers.
Evaluates provider performance via Enterprise Provider Dashboard and develops performance action plans.
Completes new provider orientation for all applicable product lines to educate on policies and initiatives, resolve issues, and educate staff/providers. In addition, drives adoption and utilization of RxEffect, P4Q, Medical Home, Cultural Competency, FWA, open/closed panels, ADA, PaySpan, ER overuse, etc.
Establishes consistent and strong relationships with provider groups utilizing an account management approach.
Establishes and leads cross-functional communication with internal departments.
Collaborates with internal cross-functional team to support provider performance and resolve barriers and challenges.
Drives improvement of provider performance by analyzing, interpreting, communicating utilization and quality metrics. Responsible for developing and executing performance improvement plans.
Understand and explains fee-for-service reimbursement to providers and management.
Understands fee-for-service contractual arrangement and works with internal support team to resolve provider contractual inquiries.
Plans, prepares and executes effective group meetings/discussion with proper objectives and expected outcomes with internal and external customers.
Maintains provider data integrity including monitoring provider credentialing, location additions, demographic updates, and terminations.
Provides continual training to assigned providers on wellcare.com portal and other resources to assist with claims, authorizations, member benefits, etc.
Provides oversight of delegated functions, as applicable.
Performs special projects as assigned.
Partners with Network Development to identify network gaps and suggests additional providers for recruitment to ensure network adequacy.
Required A Bachelor's Degree in a related field
Required or equivalent work experience
Required 1 year of experience in a Provider Relations, Account Management, Customer Service or relevant position with demonstrated ability to perform the duties of the position
Preferred Other Experience working in a Pharmacy, healthcare, provider or HMO/PPO environment
Intermediate Demonstrated interpersonal/verbal communication skills
Intermediate Demonstrated written communication skills
Intermediate Demonstrated problem solving skills
Intermediate Demonstrated organizational skills
Intermediate Demonstrated time management and priority setting skills
Intermediate Demonstrated analytical skills
Intermediate Demonstrated customer service skills
Intermediate Ability to represent the company with external constituents
Intermediate Ability to work independently
Intermediate Demonstrated negotiation skills
Intermediate Ability to multi-task
Licenses and Certifications: A license in one of the following is required: Technical Skills:
Required Intermediate Microsoft Excel
Required Intermediate Microsoft Outlook
Required Intermediate Microsoft Word
Preferred Other Language requirements may vary by location
About us Headquartered in Tampa, Fla., WellCare Health Plans, Inc. (NYSE: WCG) focuses primarily on providing government-sponsored managed care services to families, children, seniors and individuals with complex medical needs primarily through Medicaid, Medicare Advantage and Medicare Prescription Drug Plans, as well as individuals in the Health Insurance Marketplace. WellCare serves approximately 5.5 million members nationwide as of September 30, 2018. WellCare is a Fortune 500 company that employs nearly 12,000 associates across the country and was ranked a "World's Most Admired Company" in 2018 by Fortune magazine. For more information about WellCare, please visit the company's website at www.wellcare.com. EOE: All qualified applicants shall receive consideration for employment without regard to race, color, religion, creed, age, sex, pregnancy, veteran status, marital status, sexual orientation, gender identity or expression, national origin, ancestry, disability, genetic information, childbirth or related medical condition or other legally protected basis protected by applicable federal or state law except where a bona fide occupational qualification applies. Comprehensive Health Management, Inc. is an equal opportunity employer, M/F/D/V/SO.