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Provider Network Specialist

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Job Description:

Summary: 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.

Job Responsibilities:

·         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 plan’s 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

·         Managing the inbound provider calls 

·         Managing provider calls and researching provider issues, to include- claims status, contract status, help with credentialing, provider changes- assigning complex cases to account managers.

·         May involve outbound calling related to outreach projects as needed.



·         Knowledge of health care, managed care, Medicare or Medicaid. Bachelor’s degree in healthcare or a related field preferred.

·         Claims billing/coding knowledge preferred.

·         Knowledge of Excel

·         2-4 years of experience

Skills required

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