Provider Relations Specialist Jobs

The ideal candidate for this position will have experience working in the health insurance industry interpreting managed care state and federal laws and regulations and applying them to practical daily operations. The candidate must also be familiar with PPO Network operations and oversight of policies and procedures.

In this role, you will…

• Receive, coordinate and review new and revised regulations that pertain to provider network with internal carrier and PPO vendor network policies, procedures and processes to assure compliance with state and federal regulations.
• Other duties as assigned
• Update internal regulatory tracking calendar and 50 state regulatory spreadsheet with new and revised regulations to ensure all regulatory and filings are tracked, worked on and submitted by the state due date.
• Assist the Head of Provider & Network Management and Provider Network Regulatory and Filing Team Lead on ad hoc projects that support the Provider Network Team and benefit the company as a whole
• Perform a detailed review and assessment of new and revised regulations and share understanding of how each piece impacts current organizational process and procedures and identify necessary changes and implement changes.
• Use tracking sheet and RegEd tool to receive, respond and track compliance and/or revisions of each regulation with internal and external vendor policies and procedures that need to be made to ensure regulatory compliance.
• Collect material, coordinate and file State and Federal accreditation and re-accreditation filings and regulatory reports. Thoroughly understand and review material prior to filing and respond to objections when received.
• Proactively review and identify upcoming filings several months in advance of the filing due date and request material from network vendors to ensure materials are received and ready to submit by the defined regulatory due date.
• Participate in oversight calls with PPO Networks and vendors to coordinate regulatory compliance and document meeting minutes that meet regulatory guidance.

We are looking for candidates with…

• Use of SERFF filing system preferred
• Associates Degree in Health Administration, Business Administration, Regulatory Science or an equivalent combination of education and work experience in related field.
• Two to three years of experience working in health insurance and regulatory industry
• Familiarity with health insurance operations including but not limited to, eligibility, billing, claims, PPO Network and vendor operations, etc.
• Strong writing, communication and interpersonal skills
• Familiarity with RegEd system preferred
• Proficiency with MS Office products including, Outlook, Word and Excel
• Detailed orientated problem solver with excellent time management skills and ability to meet filing due dates
• Strong Ability to interpret and apply state and federal laws and regulations
• Strong attention to detail with accountability to take ownership of all work along with strong multi-tasking skills and excellent time management skills
• Familiarity with Accreditation Filings and NCQA Standards preferred
• Health insurance industry experience preferred
• Ability to work independently and as a member of the team