The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

This is a hybrid position based at our French Camp office.

What You Will Be Doing:

Under general supervision, Provider Services Representative II is responsible for establishing and maintaining provider relationships while ensuring the efficient and effective operation and administration of provider contracts. The PSR II travels to provider sites as directed by the Manager or Director.

Our Vision:

Healthy communities with equitable access to quality care.

Our Mission:

Provide high quality healthcare for our members through community partnerships.

Essential Functions:

• Conducts regular provider site visits within assigned region, service area or caseload as assigned or in alignment with field work goals.
• Monitors, research, addresses, and resolves complex provider and operational issues that cross departmental lines and may involve senior leadership as necessary; identifies trends; prepares and submits findings and recommendations.
• Establishes and maintains provider relationships; serves as a resource to providers on health plan initiatives and requirements.
• Plans, facilitates and conducts presentations for new provider orientation, regular meetings, seminars, forums and communications with providers and their staff to inform, train, educate, and address service and administrative issues, implement plan changes, ensure compliance with policies and procedures, and other items as necessary.
• Assists in network development activities, including engaging in recruiting efforts with identified providers and identifying contract opportunities.
• Monitors Provider compliance with contractual terms; make recommendations based on findings.
• Documents requested contract changes, Provider grievances, Provider demographic changes, claims or financial issues, and other issues; work with appropriate departments to be addressed.
• Develop materials and other documents in collaboration with stakeholders; distribute and communicate to providers in a timely and effective manner.
• Collaborates, educates and promotes provider participation in quality related programs.
• Support Provider education on quality metrics and care gaps; HEDIS for Medi-Cal and chronic conditions per CMS guidelines for Medicare D-SNP.
• Participates in monitoring of provider Stars Ratings for Medicare D-SNP.
• Educates providers and monitor efforts on model of care for special needs members in Medicare D-SNP.
• Participates in Interdisciplinary Team strategies or discussions and support providers in their monitoring of their scorecard for Medicare D-SNP.
• Supports provider training and discussions related to Risk Adjustment impacting provider incentives for Medicare D-SNP.
• Creates and maintains periodic and ad hoc reports related to provider functions.
• Provides departmental training to new employees based on established guidelines.
• Assists in the development of job aids, workflows, procedures and other documents as directed; implements in a timely and effective manner; makes recommendations for revisions.
• Serves as a subject matter expert for other departments

Non-Essential Functions

• Other duties as required.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong understanding of the importance of the relationships between providers and HPSJ/MVHP.
• Basic knowledge of network development and management strategies.
• In-depth knowledge and understanding of the issues affecting providers in HPSJ’s/MVHP’s service areas.
• Basic knowledge of regulatory guidelines related to commercial or Medi-Cal/Medicaid, or Medicare D-SNP and managed care provider relations.
• In-depth knowledge of provider and/or facility contract and payment structures, and reimbursement practices, including capitation.
• Basic knowledge of medical terminology and coding.
• Interpersonal skills - interact effectively with individuals both inside and outside of HPSJ/MVHP; relates openly and comfortably with diverse groups of people.
• Basic leadership skills, including but not limited to the ability to influence without authority and motivate others.
• Commitment to and ability to facilitate the adoption of HPSJ’s/MVHP’s strategy, vision, mission and values.
• Strong oral and written communication skills, including the ability to communicate professionally and persuasively, and effectively explain complex information.
• Strong presentation skills, including but not limited to the ability to tailor presentations to a specific audience, and identify key messages.
• Strong listening skills, with the ability to accurately receive and understand messages.
• Basic conflict resolution skills, including the ability to use tact and diplomacy to diffuse emotional situations.
• Time management and organizational skills. Use time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Basic problem solving and analytical skills, including the ability to perform routine analysis and solve problems using identified data and information.
• Strong skills in Word, Excel, Windows, Outlook and PowerPoint.
• Basic mathematics skills.
• Ability to work independently and as part of a team.
• Ability to treat confidential information with appropriate discretion.
• Ability to speak and be understood in English.

What You Have:

Education and Experience

Required

• Associates degree; and
• At least two years as a provider services representative or similar role in a health plan; or
• Equivalent combination of education and experience.

Preferred

• Bachelor’s Degree

Licenses, Certifications

Required

• Valid driver’s license.

What You Will Get:

HPSJ Perks:

• Robust and affordable medical coverage including HMO and PPO plan options
• Employee Wellness Program promoting physical, mental, and financial well-being
• Dental and vision plan with multiple provider choices
• Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
• CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
• Two flexible spending accounts (FSAs)for healthcare and dependent care expenses
• Employer-Paid Term Life and AD&D Insurance
• Employer-Paid Disability Insurance
• Employer-Paid Assistance Program (EAP)
• Health Advocacy to help you navigate medical care and benefits
• Voluntary supplemental benefits including medical, legal, identity theft protection
• Online discount mall
• Tuition reimbursement
• Remote work contingent on business needs and company guidelines
• A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

We are an equal opportunity employer, and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.

Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.