Provider Network Specialist

Sedgwick

1d•$21 - $26

About The Position

By joining Sedgwick, you'll be part of something truly meaningful. It’s what our 33,000 colleagues do every day for people around the world who are facing the unexpected. We invite you to grow your career with us, experience our caring culture, and enjoy work-life balance. Here, there’s no limit to what you can achieve. Newsweek Recognizes Sedgwick as America’s Greatest Workplaces National Top Companies Certified as a Great Place to Work® Fortune Best Workplaces in Financial Services & Insurance Provider Network Specialist PRIMARY PURPOSE: To ensure clients and Managed Care Organization’s covered employees are provided information on eligibility, coverage, providers, general procedure instructions, and regulations regarding MCO services; and to work with MCO provider on physician credentialing, MCO additions and removals, network and problematic issues. ESSENTIAL FUNCTIONS and RESPONSIBILITIES ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. Works directly with clients, program managers, and MCO covered injured workers to ensure they are provided information on eligibility, coverage, provider identification, general procedure instructions, and regulations regarding Sedgwick CMS (company) MCO’S. Works with the company Medical Director and vendor partner(s) on physician identification and credentialing processes, MCO provider additions and removals, MCO network issues; makes recommendations for resolution. Contacts providers to verify new workers' compensation patients are being accepted; tracks credentialing of MCO providers. Communicates with injured workers relative to the provider pre-designation rules and procedures. Maintains MCO matrix as to the status of client's respective MCO. Communicates with clients relative to their MCO status. Ensures claims management system parameters are set for MCO flags. Responds to client and MCO covered injured workers' issues; communicates issues to upper management with solution recommendation as appropriate. ADDITIONAL FUNCTIONS and RESPONSIBILITIES Performs other duties as assigned. Supports the organization's quality program(s).

Requirements

Bachelor's degree from an accredited college or university preferred.
Four (4) years of related experience or equivalent combination of education and experience required to include three (3) years of customer service and one (1) year of analytical experience.
Thorough knowledge of MCO regulations, practices and procedures
Excellent oral and written communication, including presentation skills
PC literate, including Microsoft Office products
Analytical and interpretive skills
Strong organizational skills
Excellent interpersonal skills
Ability to work independently
Ability to meet or exceed Performance Competencies

Nice To Haves

Managed Care experience preferred.

Responsibilities

Works directly with clients, program managers, and MCO covered injured workers to ensure they are provided information on eligibility, coverage, provider identification, general procedure instructions, and regulations regarding Sedgwick CMS (company) MCO’S.
Works with the company Medical Director and vendor partner(s) on physician identification and credentialing processes, MCO provider additions and removals, MCO network issues; makes recommendations for resolution.
Contacts providers to verify new workers' compensation patients are being accepted; tracks credentialing of MCO providers.
Communicates with injured workers relative to the provider pre-designation rules and procedures.
Maintains MCO matrix as to the status of client's respective MCO.
Communicates with clients relative to their MCO status.
Ensures claims management system parameters are set for MCO flags.
Responds to client and MCO covered injured workers' issues; communicates issues to upper management with solution recommendation as appropriate.
Performs other duties as assigned.
Supports the organization's quality program(s).