Provider Network Specialist I

Job SummaryThe Provider Network Specialist I performs a variety of operational support activities, related to provider network enrollment, provider credentialing and contracting, ensuring that all casework is completed accurately, on time and in compliance with established policies, guidelines, and federal and state laws.RequirementsEDUCATIONHigh School diploma or equivalent.EXPERIENCETwo (2) years of operations support experience related to provider networking, claims processing, customer service, membership enrollment or related experience.ESSENTIAL SKILLS & ABILITIESProficiency working with MS Office Suite, such as Word and ExcelInterpersonal CommunicationVerbal CommunicationWritten CommunicationCredentialingProvider ContractsProblem SolvingDecision MakingDetail OrientationTaking InitiativesSelf-MotivationHighly OrganizedResponsibilitiesAnalyzes and maintains thorough knowledge of products, complex systems, data elements, and information from multiple external sources to accurately gather data regarding malpractice, legal, license issues, and hospital privileges while providing front facing phone and electronic correspondence customer service from receipt of internal and external mail.Meets corporate URAC guidelines while maintaining performance levels based on established department standards for production and quality.Oversees credentialing, maintains provider files, contracts, provider data maintenance, and communications. Ensures providers meet standards, contracts are upheld, and data is accurate.Performs all provider related administrative tasks such as provider enrollment, data maintenance, provider number assignment, credentialing, correspondence, document preparation, etc. Thorough documentation of actions, records and/or correspondence is required.Performs other duties as assigned.Reacts and adapts to changes in network management strategies to be aware that research findings have the potential to significantly impact Enterprise operations.Responsible for initiating and maintaining good relations with providers and their staff, PHOs, hospitals, collaborative health initiatives, and other company personnel (especially the Regional Offices, claims divisions, and customer service areas).Responsible for maintaining an operational knowledge of all commercial provider networks; including lines of business and custom networks, ABCBS, HA, and BAA coverage and guidelines, contracting requirements and a detailed knowledge of credentialing standards as well as knowledge of divisions and subsidiary operations. Applies knowledge in decisions necessary for assignment of provider numbers, credentialing of providers, and determining whether admission to networks is appropriate.Responsible for obtaining/maintaining accurate, thorough, and up-to-date records on the credentials, qualifications, demographics and reimbursement of all assigned providers.Sends correspondence to providers, PHO liaisons, and facilities to obtain and gather necessary information to be submitted to committee.Stays up to date on provider academic training programs, specialty and sub-specialty qualifications, board certification processes, general practice patterns, medical malpractice insurance, primary source verification processes, licensing boards, accreditation organizations, National Practitioner Data Bank, Health Integrity Practitioner Data Bank, and AR State Medical Board Centralized Credentials Verification Service.Works collaboratively with various internal departments, external resources, and/or providers to resolve issues, while keeping leadership informed of progress and resolutions.CertificationsSecurity RequirementsThis position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.Segregation of DutiesSegregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.Employment TypeRegularADA Requirements1.1 General Office Worker, Sedentary, Campus Travel - Someone who normally works in an office setting or remotely and routinely travels for work within walking distance of location of primary work assignment.

#J-18808-Ljbffr