Job Description


Monterey, CA

Full Time

Work Hours: Monday - Friday, 8:00 AM - 5:00 PM

6/5/2019

Network Management Specialist - Aspire Health Plan

Purpose of Position

The Network Management Specialist is responsible for managing the credentialing, re-credentialing and contracting process of affiliated provider networks, as well as verifying and managing the accuracy of provider data. This position screens, reviews and enters source documents i.e., provider contracts, amendments, fee schedules, letters, and rosters into data systems. Source data information is reviewed and data management systems are updated with provider activities such as additions, terminations and changes. Additionally, this position provides administrative support to the Independent Physician Association (IPA). Requires a highly detail oriented individual with strong organizational and prioritization skills. Experience in the healthcare field and proficiency in computer software applications including databases, spreadsheets and word processing is essential. 

Responsibilities

  • Manages all aspects of letters of interest (LOIs), credentialing, re-credentialing and contracting.
  • Ensures that information sent to the Credentialing Verification Organization is complete and timely.
  • Verifies and maintains all network, individual and/or facility/ancillary providers’ information.
  • Research, respond to, and update all inaccuracies/potential inaccuracies escalated by staff.
  • Conduct quarterly provider roster validation per CMS guidelines.
  • Support network adequacy reporting, to include annual reporting per CMS guidelines.
  • Maintain the IPA ancillary facility list (labs/free standing diagnostic centers).
  • Monitors provider disciplinary actions, and follows up accordingly.
  • Ensures and maintains overall accuracy of credentialing database.
  • Support all aspects of the IPA Credentials Committee - scheduling, agenda preparation, meeting minutes, action items, etc.
  • Prepares required credentialing reports for IPA Board Meetings.
  • Gathers data, builds/runs reports, and sends out updates.
  • Corresponds with licensing board, hospitals, certification agencies, training programs and medical groups, practitioners, office staff, provider network administrators, contracting and management to resolve issues.
  • Reviews and identifies credentialing or re-credentialing practitioners, including verification of correspondence, data entry, etc., in accordance with company policies and procedures.
  • Reviews and analyzes reports, policies and procedures, summarizes, analyzes and makes notations in reports for feedback to groups and for distribution to management and Committees.
  • Other duties as assigned. 

Competencies

  • Accountability and Dependability: Assumes responsibility for accomplishing duties in an effective and timely manner.
  • Integrity:  Consistently honors commitments and takes responsibility for actions and words.  
  • Software and Computer Skills: Proficient in the use of Microsoft Office Suite, Highly skilled at using the Internet. Must learn effectively with computer-based and/or online training.
  • Flexibility:  Demonstrates adaptability and openness to alternative solutions and flexibility when interacting with others, understanding their attitudes, needs, interests, and perspectives.
  • Inclusiveness:  The ability to network and partner with all internal and external stakeholders including broad and diverse representation of private/public and traditional/non-traditional community organizations. 

Position Requirements

  • Two (2) years of experience working with Commercial payors, Medi­Cal or Medicare in a managed care or other healthcare environment.
  • Knowledge of regulatory requirements concerning Medicare.
  • Credentialing Knowledge.
  • Knowledge of provider contracts and healthcare reimbursement.
  • Strong computer capabilities in Microsoft Office Suite and database software.
  • Highly detail oriented individual with strong organizational and prioritization skills.
  • Ability to work independently and prioritize projects and issues.
  • Ability to participate in and support the goals, vision and overall direction of a system designed to care for a population of patients across the care continuum.
  • Ability to communicate effectively and professionally, both verbally and in writing.
  • Ability to summarize information clearly, thoroughly, and quickly in writing.

Preferences

  • Bachelor's degree in a relevant subject.
  • Experience with Credentialing Verification Organizations and/or with Independent Physician Associations (IPAs).

Equal Opportunity Employer

Application Instructions

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