Posted 8 days ago
Description
Overview
The Network Representative is responsible for the establishment of a Coordinated Provider List (CPL) to provide specialty care services to patients within specific geographic regions. This role reports to the Network Director and serves as the local relationship builder with those providers. The Network Representative will use database systems to manage provider data and produce reports and analysis for Center, Specialty, MED COE and HCT leaders to support improved medical costs and specialty care utilization. The individual will work closely with leaders to develop the CPL and will educate PCPs in their geographic region about the CPL and related medical cost opportunities in their patient panels.
Essential Job Duties / Responsibilities
- Has direct accountability for total medical cost and quality of care external to ChenMed within the region.
- Builds, refines, and manages a tiered network of coordinated external specialists and facilities to form a Coordinated Provider List (CPL) for specialties outside of HCT and Specialty Care. Acts as the local relationship builder with providers and payor partners in the CPL.
- Identifies areas to improve provider service levels and quality. Leads quarterly reviews with National Specialty Directors and Network Director to discuss patterns, trends, and opportunities within the CPL.
- Meets with high-volume community specialists regularly to discuss referring trends and practice patterns related to Part B and Part D.
- Attends center meetings to obtain feedback about the CPL and educate PCPs about medical cost opportunities.
- Meets with individual PCPs regularly (usually monthly or more frequently as needed) to gain feedback about the CPL and provide education about medical cost opportunities (A, B, D).
- Collaborates with Center Dyads to analyze opportunities and support improvement initiatives within referrals, including workflow, productivity, leakage, and consult tracking.
- Coordinates utilization of CPL with Care Coordinators and Referral Managers; develops plans to reduce referral leakage.
- Maintains knowledge of medical trends, cost drivers, and cost-saving opportunities.
- Supports communication and collaboration with health plans at city/area and regional levels.
- Performs other duties as assigned and modified at manager’s discretion.
Knowledge, Skills And Abilities
- Advanced-level business acuity.
- Comprehensive knowledge of general/core job-related functions, practices, processes, and methods.
- Advanced skill in Microsoft Office Suite (Excel, Word, PowerPoint, Outlook) and competence with other required systems.
- Ability and willingness to travel locally, regionally, and/or nationally up to 80% of the time; flexible to work evenings, weekends, and/or holidays as needed.
- Team-oriented with the ability to work professionally and courteously with patients, colleagues, physicians, and other personnel.
- Strong organizational skills with the ability to prioritize and complete tasks in a timely manner.
- Spoken and written fluency in English.
- Ability to exercise independent judgment.
Education And Experience Criteria
- BA/BS degree in Healthcare or related field required, or additional experience may be considered in lieu of education on a year-for-year basis.
- 3-5 years of work experience in Healthcare or a related field required.
- Healthcare experience within the Medicare HMO population is a plus.
- A valid, active driver's license in the state of employment is required; travel within the market may be required.
- Prior experience working in a Medicare Managed Care environment preferred.
