Provider Network Specialist

Role Overview

• Primary responsibility of assigned provider group’s performance
• quality, stars and financial performance.
• Assist network managers with monthly JOC meeting preparations, research outliers in financial reports, audit reports for accuracy, assist with follow up items from meetings.
• Auditing functions: provider set up in Orinoco (demographic and fee schedules), online search tool, print directory, Periscope reports, claims payment.
• Determine root cause of issues and recommend process improvements.
• Provide clear analysis and next steps for the network team.
• Analysis of network cases and grievances , determination of track and trend or provider outreach, complete outreach as needed, prepare monthly reporting.
• Support network adequacy in existing and expansion counties.
• Contract processing, to include: obtaining contract signatures, preparing provider rosters, submitting contract load form.
• Assistance with Field Network cases, outreach to providers, documentation of resolution.
• Evaluate participation requests against network need, performance metrics, current contractual relationships, expansion efforts, access to care.
• Make recommendations to management and the national contracting team.
• Contract as directed by local leadership.
• Respond accordingly to providers.

Requirements

• 3+ years of direct provider interaction
• 3+ years healthcare experience with Medicare Advantage or other relevant experience.
• Proven track record of detail oriented work
• Ability to navigate Google or MS Suite of products as well as AI
• Experience in claims research, provider set up, root cause analysis, process improvement.

Benefits

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....