Provider Relations Representative - External
Company: Gold Coast Health Plan
Location: Camarillo
Posted on: April 2, 2026
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Job Description:
This position is intended to start January 2026. The pay range
above represents the minimum and maximum rate for this position in
California. Factors that may be used to determine where newly hired
employees will be placed in the pay range include the employee
specific skills and qualifications, relevant years of experience
and comparison to other employees already in this role. Most often,
a newly hired employee will be placed below the midpoint of the
range. Salary range will vary for remote positions outside of
California and future increases will be based on the pay band for
the city and state you reside in. Work Culture: GCHP strives to
create an inclusive, highly collaborative work culture where our
people are empowered to grow and thrive. This philosophy enables us
to create the health plan of the future and do our best work –
Together. GCHP promotes a flexible work environment. Employees may
work from a home location or in the GCHP office for all or part of
their regular workweek (see disclaimer). GCHP’s focuses on 5 Core
Values in the workplace: • Integrity • Accountability •
Collaboration • Trust • Respect Disclaimers: • Flexible work
schedule is based on job duties, department, organization, or
business need. • Gold Coast Health Plan will not sponsor applicants
for work visas. POSITION SUMMARY The Provider Relations
Representative-External is a field-based position is responsible
for ensuring effective communication, compliance, and support for
network providers, dedicating a minimum of 75% of time to provider
visits, community engagements, and on-site activities. As the
primary liaison between providers and the organization, the
representative is tasked with resolving inquiries, facilitating
onboarding processes, and delivering targeted education on
policies, regulatory requirements, and reimbursement methodologies.
Through proactive collaboration with internal departments, the
representative ensures seamless coordination for claims resolution,
contracting questions, and data management. Amount of Travel
Required: 75% Reasonable Accommodations Statement To accomplish
this job successfully, an individual must be able to perform, with
or without reasonable accommodation, each essential function
satisfactorily. Reasonable accommodations may be made to help
enable qualified individuals with disabilities to perform the
essential functions. ESSENTIAL FUNCTIONS • Initiate and maintain
effective channels of communication with GCHP network providers. •
Provide the onboarding of new GCHP network providers to ensure full
compliance with regulatory requirements. • Travel to provider
offices at a minimum of 4 working days per week. • Build and
nurture relationships with healthcare providers, community-based
organizations, and other key stakeholders in the designated region
to promote the health plan’s goals and ensure robust network
participation. • Act as a primary external point of contact for
provider inquiries, resolving issues promptly. Educate providers on
health plan policies, procedures, and compliance requirements to
enhance efficiency and service delivery. • Represent the health
plan at local events, health fairs, and professional gatherings.
Develop and deliver presentations to increase awareness and
advocate for the organization’s services within the community. •
Conduct regular provider visits to gather data, identify trends,
and assess provider performance. Provide actionable insights and
detailed reports to internal teams to support strategic
decision-making. • Work closely with cross-functional teams,
including internal provider relations teams, operations, and
customer service, to align provider activities with GCHP goals and
improve the overall provider experience. • When required, assist
departmental operations with investigating contracting questions,
including interpretation of contract language as it pertains to the
roles and responsibilities of a GCHP network provider, coding and
reimbursement methodology. • Manage and maintain GCHP network
provider data and rosters to ensure additions and terminations of
participating providers, address/demographic changes, name changes,
TIN, NPI updates and provider practice information changes are
timely and accurately submitted to all applicable operational
systems. • Facilitate first call resolution, when appropriate, for
GCHP provider questions and concerns. • Drive the resolution of
escalated questions and concerns efficiently by actively engaging
with providers, claims, contracting, and health services
departments, ensuring clear and effective communication across all
parties. • Gather, review, and submit relevant documentation needed
for to help resolve complex claims inquiries and/or claims
processing. • Educate healthcare providers about Medicare Risk
Adjustment (MRA) including but not limited to accurate
documentation, coding. • Educate healthcare providers on CMS
guidelines, compliance requirements and risk adjustment audits and
reviews. • Coordinate prompt claims resolution through direct
communications with providers, claims, contracting and health
services departments. • Be proficient and maintain knowledge of
basic claims processing, components of claims submission,
processing, payment and reimbursement methodologies and issues
resolution. • Organize, schedule, and develop training sessions for
joint operation meetings, individual provider trainings, and group
provider trainings. • Provide documentation and reports for
internal GCHP committees, detailing provider trainings, contacts,
and follow-ups. • Consistently monitor and manage the provider
roster, ensuring timely follow-ups and oversight. • Maintain
understanding of applicable federal, state, and local laws and
regulations regarding healthcare with a focus on Medicaid and
Medicare. • Notify departmental colleagues and/or leadership of
potential issues, shortfalls, and trends in GCHP provider network
to help initiate improvement opportunities. • Assist departmental
colleagues on training of contract inquiries and/or contract issues
that impact GCHP network providers’ roles and responsibilities. •
Manage disputes diplomatically to find mutually beneficial
solutions. • Articulate information, updates and policies to ensure
providers understand expectations and requirements. MINIMUM
QUALIFICATIONS Education & Experience: Please identify the nature
of education and experience such as: Associates, Bachelor’s and/or
Master’s degree (four-year college or technical school) and list
any applicable specialty or field of study. • High School Degree •
Minimum 5 years health care/managed care experience to include:
Experience in provider relations, healthcare administration, health
related customer service or a related field. • Proficient knowledge
of governmental lines of business (Medicare and Medicaid)
KNOWLEDGE, SKILLS & ABILITIES Preferred Qualifications: •
Bachelor's Degree (four-year college) • Understanding with claims
processing, reimbursement methodologies, and healthcare
regulations. • Proven track record of building and maintaining
relationships with healthcare providers or clients. • Experience in
training, onboarding, or educating providers on policies,
procedures, and compliance requirements. Technology & Software
Skills: Advanced computer skills included in the MS Office
products, specifically Word, Excel, PowerPoint, Teams and Outlook
Certifications & Licenses: A valid and current Driver's License,
Auto Insurance Professional licensure: N/A Competency Statements •
Management Skills - Ability to organize and direct oneself. •
Initiative - Ability to make decisions or take actions to solve a
problem or reach a goal. • Customer Oriented - Ability to take care
of customer needs while following company procedures. • Diversity
Oriented - Ability to work effectively with people regardless of
their age, gender, race, ethnicity, religion, or job type. •
Interpersonal - Ability to get along well with a variety of
personalities and individuals. • Time Management - Ability to
utilize the available time to organize and complete work within
given deadlines.
Keywords: Gold Coast Health Plan, La Habra , Provider Relations Representative - External, Customer Service & Call Center , Camarillo, California
