Description:

Position Summary

The Specialist will cover servicing for all Ancillary and Primary Care Physicians. Manages all Ancillary and Primary Care Physician networks by developing and maintaining relationships to drive business results within a specific geographic area. Provides service and education to Ancillary groups, primary care physicians and staff. Achieves company targets through implementation of the policies and procedures.

Duties and Responsibilities

• Completes new Ancillary and PCP orientation within fifteen (15) days of health plan effective date for all applicable health plan partners’ and product lines.
• Conducts monthly site visits to resolve issues, educate new staff/groups on policies, collect new/updated contracting information and review any changes/updates to the Network Manual or Network guidelines.
• During initial onboarding, meets with the appropriate personnel and fully explains the company’s protocols, including but not limited to, all requirements necessary to comply with standards identified in the Network Provider Manual(s).
• Achieves quarterly servicing goals to establish consistent and strong relationships with Ancillary and Primary Care offices; including but not limited to reviewing the PCP Provider Manual, network rosters, PCP Provider Portal and preferred provider listings.
• Provides oversight and education to Ancillary and Primary Care offices on inquiries and claims issues and follows-up with Network Coordinators to ensure issues get or have been resolved. Always closing the loop between all groups.
• As applicable, will forward identified network gaps to the VP of Network Management to work with Contracting Specialist to fill the deficiencies.
• Supports and services primary care/MSO centers by providing utilization reports such as the Medical Loss Ratio Report, CPT backup file, preferred group listing and other analytics available to improve and maintain the accounts.
• Liaison in conjunction with all other Network Servicing Specialists and Network Coordinators, including but not limited to, claims, credentialing, grievances and/or any other topic that may come up during visit.
• Understands and explains network physician contracts, if needed.
• Cross sells current existing networks to all ancillary and primary care offices.
• Leads research on all new contracting targeted areas to build on current database. This will allow to build existing networks and grow into additional needed territories.
• Work closely with VP of Network Management on negotiation game plan and targeted areas for the expansion of the ancillary and primary care needs.
• Weekly meetings with VP of Network Management for statuses on negotiations of groups and footprint reviews.
• Batch Geos and Geo access reports to be performed and shared, as needed.
• Strategizes for network provider and health plan retention.
• Collaboration with VP of Marketing and VP of Network Management on events hosted for Primary Care membership with Health Plan, MSO, IPA and/or Physician partners.
• Special projects as assigned or directed.

Requirements:

Knowledge

• A Bachelor’s Degree in a related field or equivalent related Network Development or Provider Relations experience.
• Minimum three (3) years’ experience in Medicaid/Medicare is preferred.
• Healthcare, provider office or HMO/PPO background preferred.
• Strong knowledge of regulatory requirements concerning Medicare and Medicaid preferred.

Skills

• Excellent problem-solving skills.
• Excellent oral and written communication skills.
• Bilingual language skills a plus.
• Intermediate Microsoft Office skills
• Deductive Reasoning.

Works well individually and/or with a team setting.

Travel

Yes, 95 % of the time or as otherwise required by the company. The employee must have a valid Driver's License.