Job Summary

Initiates dialog with prospective providers/ancillary providers (including, but not limited to, hospitals, skilled nursing facilities, skilled home healthcare agencies, and ambulatory surgical centers) based on business needs. Coordinates the initial application process for all provider types. Service providers to facilitate provider understanding of Plan Policies and Contractual Requirements. Develop and maintain positive working relationships with participating providers. Conduct analysis of business need and maintains network in compliance with business need; collaborates with marketing/sales and family practice center staff.

Responsibilities

- Initiates dialogue with prospective providers/ancillary providers based on business needs

- Guide prospective providers through application, credentialing, and contract process

- Review initial applications for completeness, timeliness, and accuracy in accordance with

established guidelines

- Conduct prospective provider site visits

- Conducts new and on-going provider orientations/trainings, as required

- Fosters provider/ancillary provider network relationships

- Establish and maintain relationships with providers/office staff

- Manages territory, inclusive of strategic network partnerships and the Plan's family health centers

- Provides general instruction and support on USFHP products, provider manual, provider directory,

Plan policies and Plan procedures

- Schedule and conduct provider office/facility visits, as required

- Research, resolve, and respond to provider/ancillary provider inquiries including, but not limited to,

participation requirements, credentialing requirements, credentialing status, contract terms,

fee schedules, reimbursement, utilization, access/availability standards, member eligibility,

consult report requirements

- Document and track inquiries received and resolution.

- Facilitate interdepartmental collaboration to resolve complex provider issues

- Partner with marketing/sales teams and participates in outreach activities/events

- Prepare analytical reports of network status including gaps/access and availability.

- Monitor contract performance through site visits, claims and data analysis.

- Monitor quality and regulatory compliance. Participate in annual HEDIS activities.

Years of Experience

- 3 to 5 year’s experience in health insurance plan provider network relations/provider contracting or health insurance/medical group credentialing preferred.

- in lieu of the above, a minimum 5 to 8 years related work experience with an Associate’s degree or Bachelor’s in progress.

- Access to personal vehicle

- Valid driver’s license

- Able to lift 20 pounds

Technical Skills

- Proficiency in Microsoft Office (2010) Word, Excel, PowerPoint, and Access.

- Must be organized and detail oriented.

- Ability to meet stringent deadlines and adjust priorities with business needs.

- Excellent communication & analytical skills.

SVCMC IS AN Equal Opportunity Employer - All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.

Job Type: Full-time

Pay: $55,000.00 - $65,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Employee assistance program
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Education:

• Associate (Required)

Willingness to travel:

• 25% (Required)

Work Location: One location

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