Provider Relations Network Specialist Jobs

Assists Contract Management group during contract negotiation by conducting some analysis and obtaining information.

Experience working closely with providers both individually and in groups to develop strategies that make a positive impact.

Experience with MS Office, particularly PowerPoint and Excel.

Strong Medicaid LTSS claims experience.

Experience presenting in groups of varying sizes.

LOCATION: This is a hybrid opportunity between remote and field work in New Jersey.

2-5 years data entry experience

Manage the provider application / onboarding process and workflow within internal systems, ensuring information is collected and documented against workflow standards.

Strong communication, attention to detail, critical thinking, problem resolution and interpersonal skills.

EPDB and SFE knowledge is preferred.

1-3 years working knowledge of RUMBA

Role will be oriented to specific workflow supporting these tasks, and will generally follow these workflow expectations towards production expectations

High school diploma, GED, or equivalent work experience

Initiates phone calls to customers, (providers/pharmacies/patients/carriers etc.) to confirm receipt of mailings, and to request action.

Provides timely response and resolution for all provider initiated inquires (phone calls, emails or faxes).

Reviews and analyzes documentation and claim data to determine validity and proper action.

Updates accounts receivable system with denial and group information.

Assists with high priority special projects

Bachelor's degree in a related field, or at least 4 additional years of experience in healthcare, network development, network management.

5-8 years experience in a Provider Relations role for a managed care plan.

Takes the front-line in establishing and maintaining strong communications with providers. Collaborates with Regional Managers and manages staff and support activities.

Solid knowledge of health plan operations required.

Assists with network strategy committee meeting and network application processing decision committees

Collaborates and monitors with credentialing teams to ensure provider compliance with provider and state contracts.

1-year experience in health insurance provider operations/data management which includes exposure to network reporting or similar analytics.

2 years’ experience as a Provider Network Reporting Analyst or equivalent experience in health insurance provider operations/data management.

5 years progressive experience as a Provider Network Reporting Analyst or equivalent experience in health insurance provider operations/data management.

Bachelor’s degree in Business Administration, Statistics or related field or equivalent combination of training/education and experience.

Acts as a resource for colleagues with less experience

Knowledge of provider data structure, including tax ID, demographics, etc.

Assist and develop Network Action Plans to ensure Network Compliance with any and/all State Network Compliance requirements

Manages Local Provider Engagement Team to Deploy National Engagement Model

Manages Local Provider Relations staff to ensure Market Leading Provider Satisfaction

Oversees the monitoring of executed provider contracts to ensure Network Access meets State requirements.

Excellent interpersonal skills and the ability to work with others at all levels

Knowledge of Medicaid Regulatory Standards for Network Access, Credentialing, Claims Processing, Provider Appeals & Disputes and Network Performance Standards

Knowledge of and experience with records, reports and file maintenance

Paid time off including vacation, sick leave, holiday, management leave

Respond to question regarding claims and UM requirements

Knowledge of computerized record-keeping techniques

Skilled at organizing work to meet schedules and timelines

Flexible work schedules including hybrid/remote options

Management requirements are adhered to including language, terms and reimbursement requirements

Demonstrates a functional knowledge of provider data and managed care provider reimbursement methodologies.

Knowledge of Managed Care concepts

Responsible for the accuracy and timely management of the provider contracts

Bachelor’s Degree or equivalent education with work experience required.

Responsible for data intake process including knowledge of relevant systems required to complete job functions.

Experience in fee schedule development using actuarial models strongly preferred.

Experience with value-based contracting such as full risk models.

Job Family: Digital and Technology

National +50 Miles away from nearest PulsePoint, National +50 Miles away from nearest PulsePoint

Works with increased independence and requires increased use of judgment and discretion.

May work on cross-functional projects requiring collaboration with other key areas.

Experience using Contract Management software including maintaining and managing databases

Draft and manage communication efforts on behalf of Network Management, Client Engagement, Compliance, and Government Programs to participating pharmacies

Bachelor’s degree in Business or related area of study, or equivalent combination of education and/or relevant work experience

Pharmacy Technician certification (CPhT) or equivalent pharmacy experience

Enhanced organizational skills with the ability to work on multiple projects simultaneously

Expert verbal and written presentation skills

Data Entry/plan build experience in Healthcare Insurance systems

This is a remote role

Bachelor’s degree or equivalent work experience preferred

Configure new clients and inforce client changes in the platform

Conduct initial and final validation of platform, client portal and census, as needed

Collaborate with resources to ensure issues are addressed and corrected prior to production completion

Time management skills and ability to meet deadlines

Bachelor's degree or equivalent experience in related field

5+ years of work experience in data analysis and reporting beyond degree

Advanced skills in Excel and Access required

Must possess strong decision making skills

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

Working knowledge of business segment systems, applications, and tools.

Working knowledge of business segment specific codes, products, and terminology.

Exposure to business segment specific policy, benefits, plan and product design and language.

Strong verbal and written communication and interpersonal skills

Strong communication, critical thinking, problem

Minimum 3 years of experience working in an administrative or project management capacity

Detail oriented and impeccable organizational skills are a must

Experience and understanding of the mental health or healthcare industry preferred

Ensure providers are set up for success before they see their first Octave client

Partner with internal cross-functional teams

Track and monitor hired pipelines of new providers

5+ years managed care provider relations experience

Strong knowledge of Pennsylvania State and CMS regulatory requirements

Benefits & Wellness Program including generous Time Off

Direct and support a team responsible for the servicing, education and communication to our provider network.

Develop and deploy provider education efforts throughout network.

Drive the effort to increase the availability of self-service tools/informatino to the provider, improving overall experience and satisfaction.