Position Summary

The Credentialing Analyst is responsible for completing healthcare providers credentialing files, complying with policies and procedures.

Duties and Responsibilities

• Quality and integrity in data.
• Primary source verifications.
• Providers clarifications.
• Identify errors, omissions or incongruencies.

Education, experience, and knowledge:

• Academic degree in Office Systems, Administrative Assistant, Medical Billing, or others related, from an accredited institution.
• At least, one year in credentialing, medical claims, or direct related position.
• MS Office applications and internet use.
• Clearinghouses, EHR, QNXT, PMHS, Portico, EZCap, Cactus, Symplr or other healthcare platforms experience, preferably.

Skills and abilities: 

• Problem solving.
• Oriented to constant analysis, focusing on details.
• Results and quality oriented.
• Time management
• Highly organized.
• Reading and interpretation of documentation in english and spanish languages.

Physical Demands

While performing the duties of this job, the employee is required to sit most of the time, use hands, fingers, verbal communications and have vision abilities, including focus.

Position Type/ Expected Hours of Work

This is a full-time position.  Monday through Friday, general time span: 8:00 a.m. to 6:00 p.m.  Occasionally, out of work time span may be required, as job duties demand.

Work Environment

This job operates in a clerical office setting and/or remote setting.  This role routinely uses standard office equipment such as computers, phones, mouse, keyboard, etc.

The work environment characteristics described here are representative of those encountered while performing the essential functions of this job.  Support tasks, tied to knowledge, can be included.

Position Summary

The Credentialing Clerk is responsible for receiving and registering in data system, credentialing documentation submitted by health care providers.

Duties and Responsibilities

• Quality and integrity in data processing.
• Credentialing file routing, to the corresponding areas.
• Primary source verifications.

Education, experience, and knowledge:

• Academic degree in Office Systems, Administrative Assistant, Medical Billing, or others related, from an accredited institution.
• At least, one year in data entry or related position.
• MS Office applications and internet use.
• Experience in the healthcare industry, preferably.

Skills and abilities: 

• Computer keyboard speed.
• Problem solving, analytical and verbal communication.
• Detailed oriented
• Reading and interpretation of documentation in english and spanish languages.

Physical Demands

While performing the duties of this job, the employee is required to sit most of the time, use hands, fingers and have vision abilities, including focus.

Position Type/ Expected Hours of Work

This is a full-time position.  Monday through Friday, general time span: 8:00 a.m. to 6:00 p.m.  Occasionally, out of work time span may be required, as job duties demand.

Work Environment

This job operates in a clerical office setting and/or remote setting.  This role routinely uses standard office equipment such as computers, phones, mouse, keyboard, etc.

The work environment characteristics described here are representative of those encountered while performing the essential functions of this job.  Support tasks, tied to knowledge, can be included.

Position Summary

The Credentialing Specialist is responsible for completing and auditing healthcare providers credentialing files, complying with policies and procedures.

Duties and Responsibilities

• Identify errors in credentialing files reported as completed, previous determinations.
• Identify gaps between credentialing and recredentialing files.
• Identify questionable data in system audit trails.
• Providers clarifications.
• Primary source verifications.
• Identify errors, omissions or incongruencies.

Education, experience, and knowledge:

• Academic degree in Office Systems, Administrative Assistant, Medical Billing, or others related, from an accredited institution.
• At least, two years in credentialing position.
• MS Office applications and internet use.
• QNXT, PMHS, Portico, EZCap, Cactus, Symplr or other healthcare credentialing platform experience.

Skills and abilities: 

• Problem solving.
• Oriented to constant analysis, focusing on details.
• Results and quality oriented.
• Confidentiality oriented
• Time management
• Highly organized.
• Policies, procedures and regulations understanding.
• Reading and interpretation of documentation in english and spanish languages.

Physical Demands

While performing the duties of this job, the employee is required to sit most of the time, use hands, fingers, verbal communications and have vision abilities, including focus.

Position Type/ Expected Hours of Work

This is a full-time position.  Monday through Friday, general time span: 8:00 a.m. to 6:00 p.m.  Occasionally, out of work time span may be required, as job duties demand.

Work Environment

This job operates in a clerical office setting and/or remote setting.  This role routinely uses standard office equipment such as computers, phones, mouse, keyboard, etc.

The work environment characteristics described here are representative of those encountered while performing the essential functions of this job.  Support tasks, tied to knowledge, can be included.

Position Summary

The Claims Examiner III is responsible for processing submitted electronic claims to ensure proper filing procedures and that processing guidelines and rules have been followed. The Claims Examiner III also validates claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis and pre-coding requirements.

Duties and Responsibilities

•Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.

•Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.

•Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.

•Analyze and adjudicate complex claims that cannot be auto adjudicated.

•Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containment measures.

•Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter.

•Follow any center for Medicare and Medicaid (CMS) changes affecting claims processing.

•Perform pre-payment audit.

•Follow company policies, procedures and guidelines to ensure legal compliance.

•Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.

•Update and maintain departmental and specialty network standards of operating procedure (SOP).

•mplies with performance standards as set forth by the department head.

Knowledge

•6+ years of Claims Adjustment experience/ previous claims processing experience.

•Knowledge in Podiatry, Orthopedic, Dermatology and/or Pain Management specialties preferred.

•Knowledge of HIPAA policies and Compliance.

•Medical Terminology including ICD (10) and CPT Knowledge.

•Associates degree preferred

Skills

•Proficient in Microsoft Office programs.

•Previous experience with systems processing.

•Research skills

Abilities

•Data Entry and Documentation skills

•Problem solving, Analytical and verbal communication skills

•Ability to interpret medical documentation

•Detailed oriented

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 7:00 a.m. to 6:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 10% travel

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

Customer Service Specialist is responsible for providing support to network providers, medical offices and billing companies. The customer service specialist will answer questions regarding eligibility, authorization, network gudelines, claims status and general health plan information.

Duties and Responsibilities

•Answer calls, from providers to verify eligibility and provide them with claims payment status.

•Search for members navigating through the TPA System and main health plan sites in order to check on member eligibility.

•Read and comprehend paid and denied claims and explain denial codes.

•Educate providers on the appeal/claim submission process and provider portal use.

•Demonstrate professional etiquette and courtesy when interacting with providers.

•Accurately and comprehensively documents all communications from providers based on organization policies and procedures through investigative research to create internal PDR’s. internal open tickets.

•Assist the Claim Department by entering appeals in the TPA System.

•Assist the health plan by providing participating physicians information within the network per line of business(LOB).

•Assist the other customer service representatives on escalated issues.

•Support coverage for mailroom

•Support coverage for EDI Specialist

•Process daily pending eligibility review for claims department workflow .

•Generate provider letter weekly for rejected claim.

•Generate and mail daily NABD & NDP letters.

•Create refund letters and upload supporting documents in the claims processing system

•Review deductibles and out of pockets accumulators’ queue for claims department

•Distribute faxes that are received daily to all departments.

•Performs other duties as assigned by Management.

Knowledge

•Specialty Network experience in Claims and/or Customer Service is preferred.

•Minimum of three (3) years of experience in the Healthcare industry.

Skills

•Fluent in English and Spanish; oral and written communication.

•Microsoft (Outlook, Excel, Work, and PowerPoint).

•Accurate Data Entry.

•Sales Skills.

Abilities

•Ability to work with patience and courtesy while attending Providers and Health Plan partners.

•Ability to communicate effectively, both verbally and in writing.

•Ability to think quickly and logically to ensure appropriate response to provider inquiries and be able to enter information into multiple screens while listening to information from Providers.

•Strong organizational skills.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 10% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

The Full-Stack Programmer is responsible for designing, coding and modifying applications, websites, and API’s from layout to function and according to a client’s specifications. Strive to create visually appealing sites that feature user-friendly design and clear navigation.

Duties and Responsibilities

•Participate in designing, developing, and maintaining overall architecture of desktop and web applications.

•Participate in designing, developing, and maintaining overall architecture of OLTP databases.

•Maintain quality and ensure responsiveness of applications.

•Collaborate with the rest of the engineering team and other departments to design and launch new applications and add features to current ones.

•Gather and maintain requirements, technical specifications, and architecture documents.

•Collaborate in the research, analysis, and implementation of new technologies.

•Effectively manage day-to-day tasks/ activities of a team of developers to effectively meet the deliverables and schedule of a large, complex software development projects

•Perform other duties and/or special projects as assigned

•Design, develop, and maintain the Provider Portal

•Document and understand department EDI/Encounter applications and processes

•Design, develop, and maintain the company’s public-facing web properties

•Assist with Encounter/Claim 837 EDI Process and Automation

•Create reports and dashboards to support information visualization for different departments

•Create solutions to integrate and move data from/to multiple systems

Knowledge

•1-2 years of experience and/or a Bachelor’s.

•Experience developing .NET Framework and .NET Core, and applications.

•Experience developing web applications with C#, VB, Web Forms, MVC, ASP.NET, JavaScript, TypeScript, XML,JSON,

•Experience with Microsoft SQL Server: create and maintain tables, views, stored procedures, and functions.

•Other SQL server skills such as SSRS, and SSIS are a plus

•Knowledge of code versioning tools such as Git Lab, Git Hub and Team Foundation is a plus

•Understanding and implementation of security and data protection

•Be willing to learn and adopt new technologies to keep up with fast pace of the programming industry

Skills

General Programming Skills, Analyzing Information, Problem Solving, Software Performance Tuning, Attention to Detail, Software Design, Software Debugging, Software Development Fundamentals, Software Documentation, Software Testing

Abilities

•Analytical and critical thinker

•Strong organizational abilities

•Self-motivated

•Good People Skills

•Fast Learner

•Problem Solver

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 7:00 a.m. to 6:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 10% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at

any time with or without notice.

Position Summary

Manages physician contracting and network development functions for developing, executing and maintaining a provider network strategy statewide. Works in concert with medical management and the Provider Servicing Department in developing actions to meet market growth and medical cost targets.

Duties and Responsibilities

•Primary duty of negotiating and executing provider contracts.
•Leads research for any Institution, Network and/or Ancillary needs using all tools available; including but not limited to: WebMD, Health Plan websites, hospitals, google, etc.
•Provider networks contracting for initial network development and/or expansion in accordance with Company goals and standards.
•Meet with the appropriate physician personnel and fully explain the Company’s protocol, which includes all requirements necessary to comply with standards identified in the Provider Manual.
•Collects complete credentialing packets per specified health plan and according to the Networks Credentialing checklist from network physicians during the contracting process.
•Ensures that the provider network consists of Board Certified/Board Eligible Specialists and/or Ancillary providers as contracted by the network.
•Manages physician network by developing relationships to drive business results within assigned geographic area.
•Liaison in conjunction with Credentialing Coordinator, for all health plans on all new contracting inquiries.
•Obtains leads for prospective physicians, manages all incoming new provider leads and follows-up with the providers on the status of their new contractual agreement per the Department’s Policies and Procedures.
•Strategizes to close all quarterly assigned Geo Access deficiencies per specialty and health plan.
•Special projects as assigned or directed.

Knowledge

•A Bachelor’s Degree in a related field or equivalent experience related Network Development or Provider Relations experience.
•Minimum three (3) years’ experience in Medicaid/Medicare is preferred.
•Healthcare, provider office or HMO/PPO background preferred.
•Strong knowledge of regulatory requirements concerning Medicare and Medicaid.

Skills

•Excellent problem-solving skills.
•Excellent oral and written communication skills.
•Bilingual language skills a plus.
•Intermediate or stronger skill level with MS Word, Excel, Outlook and PowerPoint.

Abilities

•Must be organized and have excellent time management capabilities.
•Ability to analyze data to identify trends and variance from goals.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel
Yes, 95% of the time or as otherwise required by the company.

Other Duties
Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

The Collections and Claims Examiner I is responsible for processing submitted electronic claims to ensure proper filing procedures and that processing guidelines and rules have been followed. The Collections and Claims Examiner I also validates claim or referral submissions to determine, review, or apply appropriate guidelines, coding, member identification processes, provider selection processes, claim coding, including procedure, diagnosis, and pre-coding requirements.

Duties and Responsibilities

• • Conduct analysis around various claims payment processes to ensure accuracy of system configuration and provider payments.
• • Investigate and resolve problem claims, while focusing on improving errors and problems to prevent future occurrences.
• • Perform and execute various claims process testing requests to ensure desired results are met to support accurate claims payments.
• • Analyze and adjudicate complex claims that cannot be auto adjudicated.
• • Adjudicate claims by, including but not limited to, applying medical necessity guidelines, determining coverage and completing eligibility verification, identifying discrepancies and applying all cost containmentmeasures.
• • Process medical claims by approving or denying documentation, calculating benefits due initiating a payment or denial letter.
• • Follow any center for Medicare and Medicaid (CMS) changes affecting claimsprocessing.
• • Perform pre-payment audit.
• • Follow company policies, procedures and guidelines to ensure legal compliance.
• • Update claims knowledge by participating in educational opportunities, whether system oriented or medical coding/terminology/interpretation.
• • Update and maintain departmental and specialty network standards of operating procedure(SOP).
• • Complies with performance standards as set forth by the department head.
• • Perform posting charges and completion of claims to payers in a timely fashion.
• • Assume the responsibility of receiving and sorting incoming payments with attention to credibility.
• • Following up on unpaid claims within standard billing cycle timeframe – Handle collections on unpaid accounts.
• • Accurately Post all insurance payments by line item.
• • Calling Insurance Companies regarding any discrepancy in payments if necessary – Timely follow up on insurance claim denials, exceptions or exclusions.
• • Reading and interpreting insurance explanation of benefits.
• • Obtaining referrals, medical records and authorizations as required for procedures -Make necessary arrangements for medical records requests, completion of additional information requests, etc. as requested by insurance companies.
• • Respond to inquiries from insurance companies and providers.
• • Investigate, researching and appealing denied claims
• • Regularly meet with VP of Operations – to discuss and resolve reimbursement issues or billing obstacles.
• • Updating monthly payments spreadsheets, running payment reports and current collections reports.
• • Monitor and follow up with the Health Plans regarding the aging’s.

Knowledge

• • Minimum of 1- year of Claims Adjustment experience/ previous claims processing experience.
• • Knowledge in Podiatry, Orthopedic, Dermatology and/or Pain Management specialties preferred.
• • Knowledge of HIPAA policies and Compliance.
• • Medical Terminology including ICD (10) and CPT Knowledge.
• • Associates degree preferred

Skills

• • Proficient in Microsoft Office programs.
• • Previous experience with systems processing.
• • Research skills

Abilities

• Data Entry and Documentation skills
• Problem solving, Analytical and verbal communication skills
• Ability to interpret medical documentation
• Detailed oriented

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 7:00 a.m. to 6:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 10% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

Supports the Provider Servicing Manager to achieve department goals. Answers incoming telephone inquiries from groups and assists with problem resolution of issues. Coordinates network group submissions, such as, group updates, monthly rosters, group applications and group listings to internal departments and external customers (i.e. health plan partners, PCPs and network groups).

Duties and Responsibilities

• • Supports the Provider Servicing Specialist with all network group inquires.
• • Provides oversight on inquiries and claims issues following up with respective internal departments and network groups to ensure issues and/or needs have been resolved. Providing Internal departments with any paperwork needed to take care of claims issues. Responds to Network groups and/or health plan partners to close the loop on any inquiries, issues and/or open items.
• • Reviews and processes incoming and outgoing paperwork for existing groups and network update email request and all other related functions in accordance with the department’s Policies and Procedures.
• • Liaison, in conjunction with the Provider Servicing Specialist, for all health plans.
• • Audits all group-submitted requests, associated documents, and files according to the department’s Policies and Procedures for all health plans.
• • Configures group loads on active group updates such as demographic changes, terminations, new lines of business, reimbursement changes, etc. and enters all updates into networks proprietary database.
• • Performs BatchGeo for all contract terminations, location terminations and new group location request in accordance with the department’s Policies and Procedures.
• • Bi-Monthly Group Attestations sent and ensured they are received back signed by groups. This is mandatory to obtain and store in Networks proprietary database.
• • Quarterly expiration reports check to ensure that all expired documents for groups are received within the quarter and stored in networks proprietary database.
• • Sends via email, fax blast and/or certified mail required provider notification and letters.
• • Liaison between Groups to provide Contracting detailed information requested.
• • Special Projects as assigned or directed.

Knowledge

• • Associate’s degree preferred or equivalent directly related experience.
• • Minimum 1+ years’ experience in customer service or claims with exposure to problem resolution.

Skills

• Excellent problem-solving skills
• Proficient oral and written communication skills
• Deductive Reasoning
• Works well individually and/or with team setting
• Intermediate Microsoft Office skills
• Bi-lingual a plus

Abilities

• Organizational skills
• Excellent time management
• Analytical mind frame for reviewing of data

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

This position requires less than 5% travel.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Position Summary

Manages all Specialty Physician networks by developing and maintaining relationships to drive business results within a specific geographic area. Provides service and education to Network groups and staff. Achieves company targets through implementation of the policies and procedures.

Duties and Responsibilities

• • Completes new group orientations within thirty (30) days of health plan effective date for all applicable health plan partners’ product lines.
• • Conducts monthly site visits to resolve issues, educate new staff/groups on policies, collect new/updated credentialing information and review any changes/updates to the Network Manual or Network guidelines.
• • During initial onboarding, meets with the appropriate Network Group personnel and fully explains the company’s protocols, including but not limited to, all requirements necessary to comply with standards identified in the Network Manual.
• • Achieves quarterly servicing goals to establish consistent and strong relationships with Network Group offices.
• • Provides oversight and education to Network Groups on inquiries and claims issues and follows-up with Network Group and Network Servicing Coordinator to ensure issues have been resolved.
• • As applicable, will forward identified network gaps to the Director of Contracting, Servicing and Credentialing to fill the deficiencies.
• • Liaison, in conjunction with Network Servicing Coordinator, to all health plans.
• • Understands and explains network group contracts, if needed.
• • Strategizes for network groups and health plan retention.
• • Special projects as assigned or directed.
• • Exercises discretion and independent judgment in matters involving the servicing of providers.
  Knowledge
• • A Bachelor’s Degree in a related field or equivalent related Network Development or Provider Relations experience.
• • Minimum three (3) years’ experience in Medicaid/Medicare is preferred.
• • Healthcare, provider office or HMO/PPO background preferred.
• • Strong knowledge of regulatory requirements concerning Medicare and Medicaid preferred.

Skills

• • Excellent problem-solving skills.
• • Proficient oral and written communication skills.
• • Bilingual language skills a plus.
• • Intermediate Microsoft Office skills.
• • Deductive Reasoning
• • Works well individually and/or with team setting

Abilities

• • Must be organized and have excellent time management capabilities.
• • Ability to analyze data to identify trends and variance from goals.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear. The employee is occasionally required to stand; walk and stoop, kneel or crouch. Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full-time position. Days and hours of work are Monday through Friday general time span: 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Travel

Yes, 95 % of the time or as otherwise required by the company.

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.