Provider Relations Representative - Managed Care (Irving Office) Job

Children's Health - Managed Care Careers

Job Number: 52704

Location: Dallas, TX

Date Posted: 10-2-2017


Position Summary

Responsible for managing relationships with contracted providers to educate, advocate and engage as valuable partners with the Health Plan. This partnership contributes to a positive Children’s Medical Center Health Plan (CMCHP) brand experience and ongoing utilization for plan members. Resolves provider issues including those that may cross departmental lines and escalates to senior leadership as needed. Provides superior customer service and anticipates provider needs, both individually and collectively.

Essential Duties and Responsibilities

  • Frequently works away from an office environment to promote the Health Plan to community providers
  • Provides training and customer service to new providers to optimize member experiences and plan utilization in the community
  • Works to promote a positive brand experience for providers working directly with CMCHP patient populations
  • Conducts ongoing education regarding Plan requirements
  • Establishes collaborative relations with Providers by proactively anticipating provider needs and addressing concerns promptly
  • Facilitates problem resolution with claims payment issues and other operational functions so that Providers are eager to accept CMCHP members
  • Monitors accuracy of provider information and contract terms in the applicable systems
  • Works collaboratively with other departments to meet QI, UM and data needs
  • Attends JOC with manager and assist in issue resolution
  • Ensures all messages and emails are returned with 24 hours of receipt and all provider issues are resolved promptly, using a root cause approach to resolution
  • Maintains regular in-person, telephonic and email contact with assigned providers



  • Four-year Bachelor's degree or equivalent experience, required


  • 2+ years customer service, sales, provider service or claims experience in a health care setting, required
  • 2+ years in a Managed Care/Medicaid environment, required
  • Medicaid experience, preferred

Specific knowledge, skills and abilities

  • Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
  • Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
  • Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
  • Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
  • Develop and use collaborative relationships to facilitate the accomplishment of work goals.
  • Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
  • Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
  • Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
  • Effectively manage one's time and resources to ensure that work is completed efficiently.
  • Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
  • Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
  • Assimilate and apply new job-related information in a timely manner.
  • Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.

Physical demands

  • Light - Exerting up to 20 lbs. occasionally, 10 lbs. frequently, or negligible amounts constantly and may require walking or standing to a significant degree.

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