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011230 CA-Provider Engagement & Performance

Position Summary:

The Senior Provider Relations Specialist is responsible for building, maintaining and strengthening relationships with the Commonwealth Care Alliance’s (CCA) diverse provider community – including physician, hospital, behavioral health, community-based, LTSS, and HCBS providers. This individual serves as a key liaison, proactively addressing provider needs, ensuring regulatory compliance, and supporting operational excellence to enhance provider satisfaction and member access to care.

Reporting to the Senior , Director of Delegation Partnerships., the Senior Provider Relations Account Manager will:

+ Lead provider servicing activities, including onboarding, orientation presentations, and ongoing education initiatives.

+ Serve as a primary resource for resolving provider inquiries and supporting issue resolution.

+ Collaborate in the implementation of CCA’s enterprise-wide provider engagement strategy, focused on delivering a best-in-class provider experience.

+ Utilize strategic planning and data-driven insights to identify opportunities for continuous improvement in provider relations and organizational performance.

By fostering strong partnerships and supporting process enhancements, the Senior Provider Relations Account Manager plays a vital role in helping CCA achieve its mission and goals within the provider community.

Supervision Exercised:

+ No, this position does not have direct reports.

Essential Duties & Responsibilities:

+ **Relationship Management**

+ Develop strong professional relationships with providers across all specialties -, physician, hospital, behavioral health, community based, and ancillary providers and their staff.

+ Serve as the primary liaison to the provider community, researching, resolving, and escalating complex provider issues as needed.

+ Own provider relationships to drive satisfaction, retention, and operational efficiency.

+ **Provider Education and Support:**

+ Facilitate and lead communication sessions, educating on CCA’s policies, program benefits, billing, referral and authorizations regulatory compliance, and contractual expectations. Conduct orientation and ongoing education (virtual and in-person) for new and existing providers.

+ Identify and address training needs, collaborating with internal education and training teams to develop materials.

+ **Operational Excellence:**

+ Collaborate with cross-functional teams (e.g., Claims, Credentialing, Clinical Care Management, Member Services, Provider Services, Regulatory Affairs, Marketing) to resolve provider issues and reduce administrative burden.

+ Conduct site visits when necessary and coordinate with credentialing department to ensure the collection of required applications and other credentialing documentation

+ Manage and respond to a high volume of provider inquiries while ensuring consistent follow through on resolution of issues

+ Prioritize and organize own work to meet deadlines

+ Work collaboratively with Provider Network Management staff to ensure an adequate and appropriate provider network When necessary, participate in contracting strategy discussions around potential recruitment opportunities

+ Coordinate with other CCA departments, including Clinical Management, Member Services, Claims, Regulatory Affairs, Outreach and Marketing, to resolve provider issues. Attend and participate in department staff meetings

+ Assists in the development of training materials and training of Provider Relations Specialists.

+ Assist with designated provider communication tasks.

+ Special projects as assigned or directed

Working Conditions:

+ Standard office conditions.

+ This is a remote or hybrid role with the expectation of working according to Commonwealth Care Alliance’s standard operating hours of 8:30am-5pm Monday-Friday.

Required Education (must have):

+ Bachelor's Degree or equivalent experience

Desired Education (nice to have):

Required Licensing (must have):

Desired Licensing (nice to have):

MA Health Enrollment** **(required if licensed in Massachusetts):

+ No, this is not required for the job.

Required Experience (must have):

+ 5+ years of experience

Desired Experience (nice to have):

+ Experience with dual-eligible (DSNP) populations preferred.

Required Knowledge, Skills & Abilities (must have):

+ Strong claims experience

+ Mentoring subject matter expert of the team

+ Managed Care experience (preferably Medicare/Medicaid)

+ Experience in health plan provider relations

+ Experience with behavioral health providers preferred

+ Understanding of provider office operations as they relate to health plans

+ Knowledge of billing practices and reimbursement methodologies

+ Excellent verbal, written and presentation skills

+ Outstanding Customer Service Skills

+ Intermediate Microsoft Office competency, including Outlook, Word, Excel & Power Point

+ Ability to interact well with individuals on all levels, and maintain a professional image and attitude

+ Strong analytical, problem solving, and project management skills

+ Detail oriented, with the ability to organize and manage multiple priorities

Valid Driver’s license and reliable insured automobile required

Required Language (must have):

+ English

Desired Knowledge, Skills, Abilities & Language (nice to have):

EEO is The Law

Equal Opportunity Employer Minorities/Women/Protected Veterans/Disabled

Please note employment with CCA is contingent upon acceptable professional references, a background check (including Mass CORI, employment, education, criminal check, and driving record, (if applicable)), an OIG Report and verification of a valid MA/RN license (if applicable). Commonwealth Care Alliance is an equal opportunity employer. Applicants are considered for positions without regard to veteran status, uniformed service member status, race, color, religion, sex, national origin, age, physical or mental disability, genetic information or any other category protected by applicable federal, state or local laws.