Health Plan Provider Operations Specialist

AltaMed•Montebello, CA

About The Position

Grow Healthy If you are as passionate about helping those in need as you are about growing your career, consider AltaMed. At AltaMed, your passion for helping others isn’t just welcomed – it’s nurtured, celebrated, and promoted, allowing you to grow while making a meaningful difference. We don’t just serve our communities; we are an integral part of them. By raising the expectations of what a community clinic can deliver, we demonstrate our belief that quality care is for everyone. Our commitment to providing exceptional care, despite any challenges, goes beyond just a job; it’s a calling that drives us forward every day. Job Overview This Specialist, Health Plan Provider Operations position is responsible for the maintenance of provider data as well as Health Plan paneling operations for the entire Altura network. The Health Plan Provider Operations Specialist will ensure providers are listed accurately with all applicable contracted health plans and across all applicable lines of business. This individual will monitor, assess, validate, and implement standard paneling procedures to ensure health plan alignment with organizational goals. The position acts as a liaison between Altura and health plans to ensure changes are made to the Provider Network. In addition, the individual is responsible for ensuring the quality of contracts initiated by the Contracting department to ensure compliance and that business rules are met. Focusing on program and process compliance, this position will ensure regular, periodic evidence-based reviews and audits of internal processes and will assist with identifying potential risk areas. Partners with multiple internal /external customers to measure progress against goals, identify trends, implement process improvements, and make recommendations for required training or performance management.

Requirements

Bachelor’s degree preferred, or relevant work experience required
Minimum of 1 year of credentialing and/or provider relations experience required
Minimum of 1 year of interaction with multiple health plans preferred
Minimum of 2 years of experience using SQL databases preferred
Knowledge of managed care preferred

Responsibilities

Maintenance of provider data
Health Plan paneling operations for the entire Altura network
Ensure providers are listed accurately with all applicable contracted health plans and across all applicable lines of business
Monitor, assess, validate, and implement standard paneling procedures to ensure health plan alignment with organizational goals
Act as a liaison between Altura and health plans to ensure changes are made to the Provider Network
Ensure the quality of contracts initiated by the Contracting department to ensure compliance and that business rules are met
Ensure regular, periodic evidence-based reviews and audits of internal processes
Assist with identifying potential risk areas
Partner with multiple internal /external customers to measure progress against goals, identify trends, implement process improvements, and make recommendations for required training or performance management