Provider Network Specialist

JOB SUMMARY

Serves as the liaison between the Plan and our network of healthcare providers. Develops and maintains relationships with the provider network community. Responsible for educating the network on Plan standards and TRICARE requirements. Responsible for new provider orientation program and ongoing training to ensure understanding of Plan policies, programs, TRICARE requirements and contractual obligations. Monitors network adequacy and responds appropriately; collaborates with marketing/sales and family practice center staff to ensure beneficiaries needs are fulfilled. Serves as the primary point of contact to address inquiries and resolve issues; track, trend and report provider inquiries/issues to management.

RESPONSIBILITIES

• Actively communicate with prospective and contracted providers based on business needs.
• Guide prospective providers through application, credentialing, and contract process (provider onboarding).
• Conduct prospective provider in person site visits, as applicable to Plan requirements.
• Conducts new provider orientation and on-going provider trainings, as required.
• Foster and promote positive provider network relationships.
• Develop and strengthen relationships with providers/office staff and key stakeholders.
• Maintain an accurate list of contacts, including but not limited to, Managed Care, Credentialing, Claims, Contracting, Quality and Population Health executives and/or representatives.
• Manages territory, inclusive of strategic network partnerships and the Plan’s family health centers and marketing staff.
• Serve as the primary point of contact, providing general instruction and support on all USFHP products, provider manual inquiries, accuracy of the provider directory, ensuring data integrity, adherence to Plan policies and Plan procedures; claims management.
• Schedule and conduct provider office/facility visits to all high-volume providers in accordance with department project plan and initiatives.
• Investigate, resolve, and respond to provider inquiries including, but not limited to, participation requirements, credentialing requirements, credentialing status, contract terms, fee schedules, claims management, reimbursement, utilization, access/availability standards, member eligibility, consult report requirements, provider payment configuration.
• Document and track inquiries received and monitor towards resolution in accordance with Plan policy and TRICARE regulations.
• Facilitate interdepartmental collaboration to resolve complex provider issues; track and trend issues.
• Partner with marketing/sales teams and participate in outreach activities/events, targeting market growth, penetration and building brand recognition.
• Prepare analytical reports of network status including gaps/access and availability.
• Monitor contract performance and network adequacy through site visits, claims and data analytics.
• Enforce quality and regulatory compliance guidelines; participate in HEDIS activities.
• Collaborate with Quality Department (HEDIS) to help reinforce Plan quality standards and increase positive patient outcomes.
• Additional inter/departmental duties as assigned

YEARS OF EXPERIENCE

• Required experience: 5-8 years’ experience in health insurance, provider network or provider contracting.

• Able to lift 20 pounds.

TECHNICAL SKILLS/COMPETENCIES

• Proficiency in Microsoft Office: Word, Excel, PowerPoint – Access and Salesforce
• Strong organizational skills and detail oriented
• Excellent presentation skills
• Excellent data entry skills
• Ability to meet stringent deadlines and adjust priorities to meet business needs
• Excellent communication & analytical skills
• Medical and managed care terminology

Education/Certifications/License

• High School Diploma
• Valid Driver’s license and access to a personal vehicle

SALARY RANGE: $70,000.00 - $75,000.00

Benefits Statement:

*SVCMC, Inc. provides a robust benefits package that includes medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services. Employees also receive vision coverage through UnitedHealthcare Vision and dental benefits through MetLife. Basic life and disability insurance are automatically provided at no cost. All employees are eligible for commuter benefits, tuition reimbursements, and a 401(k) retirement plan with an immediate employer match that is fully vested from day one. SVCMC also offers a generous time off package…