Provider Network Specialist I
Posted on: 16 Feb 2021
Newark, NJ
Job Description
Position Purpose:
Perform duties to act as a liaison between providers, the health plan and Corporate. Perform training, orientation and coaching for performance improvement within the network and assist with claim resolution.
* Serve as primary contact for providers and act as a liaison between the providers and the health plan
* Conduct monthly face-to-face meetings with the provider account representatives documenting discussions, issues, attendees, action items, and research claims issues on-site, where possible, and route to the appropriate party for resolution
* Receive and effectively respond to external provider related issues
* Provide education on health plans innovative contracting strategies
* Initiate data entry of provider-related demographic information changes and oversee testing and completion of change requests for the network
* Investigate, resolve and communicate provider claim issues and changes
* Educate providers regarding policies and procedures related to referrals and claims submission, web site usage, EDI solicitation and related topics
* Perform provider orientations and ongoing provider education, including writing and updating orientation materials
* Ability to travel
Education/Experience:
Bachelor's degree in related field or equivalent experience. 0-2 years of provider relations or contracting experience. Knowledge of health care, managed care, Medicare or Medicaid. Bachelor's degree in healthcare or a related field preferred. Claims billing/coding knowledge preferred.
Licenses/Certifications: Current state driver's license.
Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law.
WellCare
Tampa, FL
WellCare Health Plans, Inc. provides government-sponsored managed care services. The company operates in three segments: Medicaid Health Plans, Medicare Health Plans, and Medicare Prescription Drug Plans (PDPs). The Medicaid Health Plans segment offers plans for beneficiaries of temporary assistance for needy families, supplemental security income, and aged blind and disabled residents; and other state-based programs, such as children's health insurance programs and long-term services and supports programs for qualifying families who are not eligible for Medicaid.
The Medicare Health Plans segment provides Medicare, a federal program that provides eligible persons aged 65 and over, as well as some disabled persons with a range of hospital, medical, and prescription drug benefits; Medicare Advantage, a Medicare’s managed care alternative to the original Medicare program, which offers individuals standard Medicare benefits directly through Centers for Medicare & Medicaid Services; and coordinated care plans that are administered through health maintenance organizations and require members to seek health care services and select a primary care physician from a network of health care providers.
The Medicare PDPs segment provides Medicare part D PDP plans to Medicare-eligible beneficiaries. Its PDP plans offer national in-network prescription drug coverage, including a preferred pharmacy network. As of December 31, 2018, the company served approximately 5.5 million members in the United States. WellCare Health Plans, Inc. was founded in 1985 and is headquartered in Tampa, Florida.
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IndustryHealthcare
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No. of Employees12, 000
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Website
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Jobs Posted917
