Provider Network Relations - West Coast

Company Overview

CSTS Customer Service and Technology Solutions LLC is a leading third-party administrator for Ultimate Health Plans and is dedicated to enhancing the healthcare experience. We specialize in managing the administrative and operational aspects of insurance plans, ensuring compliance with federal regulations while providing exceptional service to our partners.

Position Summary Primary responsibility includes negotiations of physician/provider contracts and ongoing education / service to the physician / provider network in assigned market areas. Establishes and maintains ongoing relationships with the health plan’s network of physicians, groups, hospitals, and ancillary providers. Company provides a car allowance and cell phone allowance.

Essential Duties and Responsibilities include the following. Other duties may be assigned

Conducts monthly service-educational visits to primary care physician offices

Collaborate with sales team in making presentations to members and brokers

Conducts monthly service/educational visits to targeted high volume/key specialty offices

Conducts new provider orientations and educates providers regarding policies and procedures related to referrals, claims submission, credentialing documentation, web site education, etc.

Works in cooperation with assigned Claims Department staff to conduct periodic service/educational visits to all participating hospital billing departments

Manages provider demographic information changes (tax identification numbers, new addresses, etc.) and resolves identified problems

Conducts a quarterly audit for each line-of-business and provider category to determine ongoing network needs and provides written network development goals

Identifies, on a semi-annual basis, opportunities for re-negotiation of contracts by line-of-business and provider category and written re-negotiation goals

Negotiates contracts within approved rate reimbursement arrangements

Utilizes service guidelines to maintain network stability as it relates to provider terminations and panel closing by primary care physicians

Implements, through service visits, educational tools for physician/providers and their practice staff

Works closely, in assigned markets, with the Marketing / Sales Department staff and primary care physician practices to achieve/exceed membership growth projections within guidelines

Abides by all compliance requirements for the Department of Financial Services Office of Insurance Regulation (DFS/OIR), Agency for Health Care Administration (AHCA) and the Centers for Medicare and Medicaid Services (CMS) as these apply to Provider Relations Department activities

Builds strong relationships with providers and specialty care providers

Maintains reference materials to support appropriate network utilization and program participation

Works with new specialist providers in an effort to maintain continuity within the broad network

Resolves high level claims issues while maintaining positive relationships

Supervisory Responsibilities

This job has no supervisory responsibilities.

Requirements

• Proven experience in provider relations or a similar role within the healthcare industry.
• Strong interpersonal and communication skills to effectively engage with diverse stakeholders.
• Ability to analyze data and metrics related to provider performance.
• Familiarity with healthcare regulations and compliance standards is preferred.
• Proficient in using technology tools relevant to provider management.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education and/or Experience

Bachelor's degree (B. A.) from four-year College or university; or three to five years related experience in Medicare contracting, provider relations, provider servicing; or equivalent combination of education and experience.

If you are passionate about transforming the healthcare experience and building meaningful relationships, we invite you to apply today and become a vital part of our mission at CSTS!

CSTS is an Equal Opportunity Employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All employment decisions are based on business needs, job requirements, and individual qualifications, without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status

Job Type: Full-time

Pay: $55,000.00 - $75,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: Remote