Provider Services Representative

Date: Sep 28, 2022

Location: Rancho Cucamonga, CA, US

Company: Inland Empire Health Plans

Job Requisition ID: 7405 


Position Summary/Position


The Provider Services Representative is responsible for developing and maintaining strong and consistent relationships with IEHP Providers. Routinely communicate organizational policies, procedures and processes, anticipate and responds to Provider educational needs and conduct ongoing Provider and office staff trainings.  Integral to the implementation of network improvement plans with PCPs, Specialists, Vision Providers, Behavioral Health Providers and IPAs in order to meet IEHP quality metrics, service goals and compliance standards.

Major Functions (Duties and Responsibilities)


1. Conduct Provider orientations, continuous training and education to Providers and office staff.  Maintain accurate and timely log of Provider visits in compliance with NCQA standards, and DHCS and CMS regulatory requirements.
2. Act as a Provider Advocate and liaison between Providers and IEHP departments in resolving Member, Provider and IPA issues and concerns.
3. As assigned visit all IEHP Providers on a periodic basis, focusing visits, strategically under the direction of the Provider Relations management team, on high volume Providers and in alignment with IEHP’s quality initiatives and strategic priorities.  
4. Monitor and support Providers through utilization reports, Provider Report Cards, quality data and cases presented through the Customer Relationship Management (CRM) tool to provide training to improve Provider performance, close care gaps and improve access to care.
5. Lead investigation and resolution of Provider grievances.
6. Promote electronic submission capabilities including the timely and complete submission of encounter data, claims and utilization data related to IEHP’s quality metrics, namely HEDIS.
7. Communicate with IPA staff regarding Provider issues, quality initiatives and Provider changes, and to resolve Member and Provider cases.
8. Maintain a strong partnership with the BH Department ensuring that there’s constant internal communication and coordination to support BH Providers in their day-to-day operation.
9. Attend internal meetings with BH Department and participate in external Provider meetings and focus groups.
10. Assist Providers with interpreting IEHP reports, including eligibility, capitation, claims and quality reports.
11. Communicate changes regarding Provider information in to ensure timely update of systems and directories.  Prepare coverage plans for the compliant transfer of Member PCP assignments.
12. Coordinate with Contracts Department to address Provider inquiries concerning rate/service changes and claims disputes.
13. Assist with the development of the Provider Policy and Procedure Manual as requested.
14. Assist with the development of written communication to the Provider network as requested.
15. Lead JOMs with IPAs as scheduled and as assigned.
16. Visit all designated Providers (Primary Care Physicians, Specialists, Behavioral Health Providers and Vision Providers) on a periodic basis, focusing visits strategically under the direction of the Provider Relations Management Team on high volume Providers and in alignment with IEHP’s quality initiatives and strategic priorities.  
17. As applicable, review and verify compliance of the Specialists Network, identifying gaps and requesting IPA response and submission of Specialist credentialing to close network gaps.
18. Review and verify Provider Directory information and lead investigation and resolution of reported Provider Directory inaccuracies.

Supervisory Responsibilities

Leading: Self

Experience Qualifications


Three (3) or more experience with customer service.  One to two (1 to 2) years of experience including Hospital, Managed Care, Medical Group, IPA and HMO.  Experience with managed care.

Education Qualifications

Bachelor's degree from an accredited institution required.

Drivers License Required

Yes, must have a valid California Driver's license and valid automobile insurance. Must qualify and maintain driving record to drive company vehicles based on IEHP insurance standards of no more than three (3) points.

Knowledge Requirement


Working knowledge of Medical Group IPA and HMO operations.

Skills Requirement


Strong organizational skills. Excellent written and verbal communication and interpersonal skills.  Microcomputer Applications (Microsoft Word and Excel, Access Preferred) for use in all aspects of an office environment.  Skilled data input. 

Abilities Requirement


Possess telephone courtesy with a high level of patience.

Commitment to Team Culture


The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions


Data entry involving computer keyboard and screens, automobile travel within the IEHP service area, distribution of reports and supplies to outside provider offices. 

Physical Requirements

Keyboarding: Traditional - FREQUENTLY
Keyboarding: 10-Key - FREQUENTLY
Keyboarding: Touch-Screen - FREQUENTLY
Hearing: One-on-One - FREQUENTLY
Communicate: Information/ideas verbally - FREQUENTLY
Regular contacts: co-workers, supervisor - FREQUENTLY
Understand and follow direction - FREQUENTLY
Regular and reliable attendance - CONSTANTLY

A reasonable salary expectation is between $61,422.40  - $78,312.00, based upon experience and internal equity.


Inland Empire Health Plan (IEHP) is the largest not-for-profit Medi-Cal and Medicare health plan in the Inland Empire. We are also one of the largest employers in the region. With a provider network of more than 7,000 and a team of more than 2,500 employees, IEHP provides quality, accessible healthcare services to more than 1.5 million members. And our Mission, Vision, and Values help guide us in the development of innovative programs and the creation of an award winning workplace. As the healthcare landscape is transformed, we’re ready to make a difference today and in the years to come. Join our Team and make a difference with us! IEHP offers a competitive salary and a benefit package with a value estimated at 35% of the annual salary, including medical, dental, vision, team bonus, and state pension plan.


Nearest Major Market: Riverside
Nearest Secondary Market: Los Angeles