Provider Network Specialist

Overview

The position supports the Managed Care / Network Management Department. Primary responsibilities include processing ALL new contracts, provider additions, updates/changes, and terminations for primary care physicians, specialists, ancillary vendors, hospitals, and independent providers for the IPA, Clinic, PACE, DVL-HIV, Independent, and the Multipurpose Senior Services Program (MSSP). Such requests are typically received and processed from contracted and non-contracted providers via the Provider Line and Provider Support email queue. Additional requests are also received and processed from internal stakeholders such as credentialing, marketing, business development, provider data management, and clinic administration. See Essential job functions below for more detailed information.

Responsibilities

Accurately process ALL new contracts, provider additions, changes/updates, and terminations.

Serve as an internal liaison between providers and the Network Management Department responding timely to the Provider Telephone Line and Provider Support Email queue.

Address and facilitate requests received relative to contracting, provider data management, configuration, claims, referrals, AltaMed Net, and EZ-CAP with the respective personnel.

For new contracts/amendments, obtain updated W9, facility site review, and all required data elements via the Provider Assessment Form for consideration into the network.

Per Compliance, conduct preliminary background check for new providers via Streamline Verify (OIG Exclusions List), Medi-Cal provider enrollment, Medicare provider enrollment, and NPPES NPI Registry.

Coordinate efforts with the Provider Network Administrator to obtain approval of rates for contract negotiations.

Upon approval of rates, send contracts and credentialing resources to provider for signature to include follow-up. If denied, send letters to providers.

Upon receipt of signed contracts from the providers, complete the New Contract Request Form and initiate the next phase of the contracting process in Compliance 360 for department and accountability purposes to include uploading streamline verify documents, W9, PAF, and partially executed contract. This task initiates the credentialing process.

Monitor approval of credentialed providers in an effort to execute contracts with the completion of the CEO Signature Request Form.

Upon receipt of CEO's signature, upload executed contract in C360 to initiate next phase of the contracting process for the Provider Data Management Department to upload practice/provider demographics, followed by configuration of rates and accurately reflecting provider in AltaMed Net.

Manage and process C360 rejections received from Credentialing, Provider Data Management, Configuration, AltaMed Net, and Provider Oversight due to incomplete information, etc. that are returned to the Network Management Department.

Utilize Microsoft Access Contracting Database to enter and track ALL contracting efforts including status. This includes adherence to proper naming conventions for consistent filing and reporting purposes.

For additions/updates/changes/terminations, receive and complete respective Contract Request Form for submission via C360 routing to credentialing, provider data management, configuration, AltaMed Net and Provider Oversight in an effort to update proper systems.

For provider terminations, work with the Provider Network Administrator to obtain default providers ensuring alignment with region, specialty, age limits, and health plan assignment. Send out termination letters to include the effective date according to the terms of the contract and updating the Microsoft Access Contracting Database for reporting purposes.

Effectively articulate/delegate necessary tasks to the Provider Network Administrators for missing and/or relevant information to process all requests.

Consistently utilize and update resource tools available for the job. May be involved with the design of programs used to manage Contract Request Forms.

Assists in the formulation of policies and procedures to ensure compliance with managed care contracts.

Generate reporting on the production of Contract Request Forms for accountability purposes, analysis, maintaining appropriate record keeping for provider orientations, performance reviews, and health plan audits.

Provide professional and efficient customer service. Assist with covering duties for the Administrative Assistant, as needed.

Performs other related duties and projects as assigned.

Qualifications

Four-year college degree in health care or equivalent years of related work experience preferred.

Extensive knowledge of managed care, provider network management, or contracting principles preferred.

MinUSD $29.52/Hr.MaxUSD $45.76/Hr.Employment Type: OTHER