Provider Relations Specialist V - Provider Services

The ideal candidate is a strategic leader with experience in healthcare delivery, managed care operations, customer relationship management, and provider relations. They have demonstrated leadership experience and a proven ability to build strong provider partnerships, improve provider satisfaction, and ensure regulatory and contractual compliance. This individual excels at collaborating with cross-functional stakeholders, driving process improvements, analyzing provider and market data, and implementing solutions that improve access to care and operational performance. Strong communication, relationship-building, project management, and problem-solving skills are essential, along with the ability to influence stakeholders and lead complex initiatives that support organizational and provider network success.

Note: Work location is on-site with the flexibility to work remotely, the primary location will be in-office for meetings, per Kaiser Permanente-s Authorized States Policy - Employees may be required to travel to a Kaiser Permanente or customer site. Residency required in the primary location: 9 Piedmont Center, 3495 Piedmont Rd., NE, Atlanta, Georgia 30305

Job Summary:

In addition to the responsibilities listed below, this position is also responsible for leading the planning, development, and implementation of provider satisfaction strategies to improve network relationships and enhance provider engagement; overseeing the development of provider relations programs to facilitate effective provider communications and problem resolution; and creating and distributing media materials (e.g., articles and newsletters), publications, and manual updates to providers; ensuring providers adhere to regulatory and contractual requirements; leading the escalation of complex compliance issues to appropriate parties; supporting organizational responses to regulatory audits; and leading the delivery of provider education and/or onboarding.

Essential Responsibilities:

• Promotes learning in others by communicating information and providing advice to drive projects forward; builds relationships with cross-functional stakeholders. Listens, responds to, seeks, and addresses performance feedback; provides actionable feedback to others, including upward feedback to leadership and mentors junior team members. Practices self-leadership; creates and executes plans to capitalize on strengths and improve opportunity areas; influences team members within assigned team or unit. Adapts to competing demands and new responsibilities; adapts to and learns from change, challenges, and feedback. Models team collaboration within and across teams.
• Conducts or oversees business-specific projects by applying deep expertise in subject area; promotes adherence to all procedures and policies. Partners internally and externally to make effective business decisions; determines and carries out processes and methodologies; solves complex problems; escalates high-priority issues or risks, as appropriate; monitors progress and results. Develops work plans to meet business priorities and deadlines; coordinates and delegates resources to accomplish organizational goals. Recognizes and capitalizes on improvement opportunities; evaluates recommendations made; influences the completion of project tasks by others.
• Supports continuous improvement efforts by: leveraging innovative and data-driven approaches to identify and/or consult on continuous improvement opportunities across the contract ecosystem (e.g., identifying business and operational disparities between organizational and provider expectations, constraints, and risks to accessible care, building and maintaining relationships); driving the implementation of process improvement initiatives to aid providers and business goals; collaborating with internal and external partners to develop network strategies and implement improved access to care; and may also include conducting and/or collaborating in complex modeling and analyses of provider and market data to develop recommendations, solutions, and action plans for improvement initiatives.
• Ensures contract commitments are met by: validating, maintaining, and/or conducting statistical analyses on provider and contract data of the day-to-day operation and management of services to identify trends and consult on provider compliance; documenting and reporting provider activities and/or coordinating with alternate stakeholders to ensure compliance with contract terms and conditions; promoting the use of guidelines to ensure provider compliance with state and federal regulations as well as KP policies and procedures; and consulting with Provider Systems Administration (PSA) or its equivalent as needed to ensure proper contract interpretation and operational readiness and guiding corrective actions as identified through contract performance.
• Supports contract strategy development by: developing, proposing, and implementing short-term strategies that improve access to patient care while managing outside service costs; providing in-depth and advanced consultation on local service delivery planning and delivery system leadership to aid in the achievement of provider priorities and strategies; may include leading collaborative cross-functional workgroups to ensure provider strategies meet the unique needs of diverse stakeholders; and may also include developing materials and/or conducting peer training for new hires and contingent workers (e.g., establishing contract language, determining payment rate parameters, defining workflow and business processes, and ensuring cross-training across all service lines).
• Grows the Provider Network by: reviewing or identifying recommended/potential partners/alliances for assigned service area to fill service gaps or decrease costs in current service offerings using advanced knowledge of current service gaps; developing, maintaining, and managing trusted partnerships with providers to understand their unique service request needs and challenges; serving as a liaison between providers and KP by coordinating communication efforts (e.g., contract compliance such as access, availability, referral operations, and/or supporting member complaints); and supporting provider site visits, daily interactions, and ad hoc meetings by aiding in developing itineraries and agendas, gathering credentialing materials, and/or initiating this process.
• Contributes to provider satisfaction by: leveraging specialized knowledge of provider/contract operations to consult on issues that arise from contract configuration/interpretation and/or related to claims/disputes, billing, payment, reimbursement, directories, other operational issues, and/or directories; leveraging innovative solutions to ensure requests for information, questions, and problems are efficiently identified, documented, and addressed; and in some instances, collaborating on and acting as a role model in the creation and delivery of complex training materials to aid provider education and orientation on health plan systems, processes, and/or credentialing.

Knowledge, Skills and Abilities: (Core)

• Ambiguity/Uncertainty Management
• Attention to Detail
• Business Knowledge
• Communication
• Critical Thinking
• Cross-Group Collaboration
• Decision Making
• Dependability
• Diversity, Equity, and Inclusion Support
• Drives Results
• Facilitation Skills
• Health Care Industry
• Influencing Others
• Integrity
• Learning Agility
• Organizational Savvy
• Problem Solving
• Short- and Long-term Learning & Recall
• Teamwork
• Topic-Specific Communication

Knowledge, Skills and Abilities: (Functional)

• Internal or External Publication
• Provider Data Systems/Processes
• Applied Data Analysis
• Business Acumen
• Business Planning
• Business Process Improvement
• Business Relationship Management
• Compliance Management
• Computer Literacy
• Consulting
• Health Care Reimbursement
• Interpersonal Skills
• Key Performance Indicators
• Knowledge Management
• Presentation Skills
• Project Management
• Quality Assurance Process
• Time Management
• Training
• Trend Analysis
• Written Communication

Minimum Qualifications:

• Minimum three (3) years of experience in a leadership role with or without direct reports.
• Bachelors degree from an accredited college or university AND minimum seven (7) years of experience in health care delivery or operations in a managed care environment, customer relationship management, or a directly related field OR Minimum ten (10) years of experience in health care delivery or operations in a managed care environment, customer relationship management, or a directly related field.

Preferred Qualifications:

• Two (2) years of experience working with Microsoft Excel, including working with formulas and developing integrated workbooks.
• Four (4) years of experience with industry standard claims coding and submission processes.