logo

View all jobs

Provider Network Specialist II

Springfield, MO · Healthcare
About the Company: 
A Fortune 500 company, is a diversified, multi-national healthcare enterprise that provides a portfolio of services to government sponsored healthcare programs, focusing on underinsured and uninsured individuals.  Many receive benefits provided under Medicaid, including the State Children's Health Insurance Program (CHIP), as well as Aged, Blind or Disabled (ABD), Foster Care and Long Term Care (LTC), in addition to other state-sponsored/hybrid programs, and Medicare (Special Needs Plans).  

The Company operates local health plans and offers a range of health insurance solutions.  It also contracts with other healthcare and commercial organizations to provide specialty services including behavioral health management, care management software, correctional healthcare services, dental benefits management, in-home health services, life and health management, managed vision, pharmacy benefits management, specialty pharmacy and telehealth services.


Position Overview:
Perform health plan provider orientations and conduct ongoing educational outreach with a focus on improving quality and financial outcomes within the provider network. Act as liaison between providers and the health plan to enhance the business relationship.


Responsibilities: 
  • Conduct initial provider orientations as well as ongoing educational outreach
  • Educate providers regarding policies and procedures related to referrals, claims submission, credentialing documentation, web site education, Electronic Health Records, Health Information Exchange, and Electronic Data Interface
  • Enhance account relationships by investigating, documenting and resolving provider matters and effectively handling and responding to account changes and correspondence.
  • Engage providers and educate them on Patient Centered Medical Home initiatives
  • Perform detailed HBR (Health Benefits Ratio) analyses, Health Information data Information Set (HEDIS) analyses, and create reports for provider Review provider performance by both quantitative metrics and qualitative factors
  • Create and communicate milestone documents, dashboards and success or improvement metrics
  • Act as a liaison between the provider and the health plan ensuring a coordinated effort in improving financial and quality performance
  • Provide information and status updates for providers regarding incentive agreements
  • Conduct site visits when required
  • Perform other contracting duties as requested, including but not limited to recommending changes to pricing subsystems, submitting changes to provider related database information and assisting in the completion of special projects
  • Ability to travel


Qualifications:
Education/Experience:
  • Bachelor’s degree in related field or equivalent experience.
  • 2+ years of combined managed healthcare and provider reimbursement experience.
  • Advanced knowledge of Microsoft Excel.
  • Clinical or health information management (HIM) experience preferred.
  • Claims processing and/or managed care experience preferred.

Licenses/Certifications:
  • Current state driver’s license.


Benefits: 
The company offers more than just medical insurance. They pay most of your benefits costs and in some cases – they pay 100 percent. Most of the benefits not covered by the company are paid with pre-tax payroll deductions. 
  • Health insurance
  • Dental insurance
  • Vision insurance
  • Flexible spending accounts (includes health care, dependent care mass transit reimbursement)
  • Short- and long-term disability insurance
  • Basic Life insurance
  • Supplemental AD&D
  • Supplemental life insurance
  • Wellness Program
  • 401(k) retirement with company match
  • Employee stock purchase plan
  • Vacation, Personal and Sick time
  • Paid Company Holidays
  • Employee Assistance Program (EAP)
  • Training and Learning Opportunities
  • Tuition Reimbursement/Educational Assistance
  • Service Awards
  • On-site fitness center or discount at local fitness centers (most locations)
  • Discounts for select local and national products and services, including cell phones, computers and more
  • Other amenities may be available, but vary by location
Kat Forester
ProEnlist, LLC

Connect with me on LinkedIn
Connect with us on Facebook

Follow ProEnlist for More Jobs

Please do NOT email the recruiter.  Applications are only accepted via the apply link.

C2C Not Available for This Position
Share This Job
Powered by