Provider Network Specialist

Devoted Health•Colorado Springs, CO

4d•$65,000 - $75,000

About The Position

A bit about this role: This role will be instrumental in analyzing provider performance (STARS, Medical Cost of Care, CAHPS), demographic information, financial data, quality reports, and special project data. The ideal candidate will assist the market team in preparing for monthly IPA meetings and Joint Operating Committee meetings.. The ideal candidate will also have knowledge of provider reporting, contract management, claims payments, provider set up, and root cause analysis. A key to success will be someone who has exhibited a proven ability to work independently, while still working with a team, exhibits strong organizational skills and is goal oriented. Your Responsibilities and Impact will include: Auditing functions: provider set up in Orinoco (demographic and fee schedules), online search tool, print directory, Periscope reports, claims payment. Determine root cause of issues and recommend process improvements. Provide clear analysis and next steps for the network team. Analysis of network cases and grievances , determination of track and trend or provider outreach, complete outreach as needed, prepare monthly reporting. Support network adequacy in existing and expansion counties. Contract processing, to include: contract management, preparing provider rosters, submitting contract load form. Assistance with Field Network cases, outreach to providers, documentation of resolution. Evaluate participation requests against network need, performance metrics, current contractual relationships, expansion efforts, access to care. Make recommendations to management and the national contracting team. Contract as directed by market leadership. Respond accordingly to providers. Assist network managers with monthly JOC meeting preparations, research outliers in financial reports, audit reports for accuracy, assist with follow up items from meetings.

Requirements

3+ years of direct provider interaction or provider performance management.
3+ years healthcare experience with medicare advantage or other relevant experience.
Proven track record of detail oriented work
Ability to navigate Google or MS Suite of products as well as AI
Experience in claims research, provider set up, root cause analysis, process improvement.

Nice To Haves

You have the desire to assist network operations in providing excellent service to our providers.
You are excited by the fast pace of the organization and accept opportunities for change.
You are willing to share your experiences to create best practices.
You are skilled at data evaluation, root cause identification, and synopsis.

Responsibilities

Auditing functions: provider set up in Orinoco (demographic and fee schedules), online search tool, print directory, Periscope reports, claims payment.
Determine root cause of issues and recommend process improvements.
Provide clear analysis and next steps for the network team.
Analysis of network cases and grievances , determination of track and trend or provider outreach, complete outreach as needed, prepare monthly reporting.
Support network adequacy in existing and expansion counties.
Contract processing, to include: contract management, preparing provider rosters, submitting contract load form.
Assistance with Field Network cases, outreach to providers, documentation of resolution.
Evaluate participation requests against network need, performance metrics, current contractual relationships, expansion efforts, access to care.
Make recommendations to management and the national contracting team.
Contract as directed by market leadership.
Respond accordingly to providers.
Assist network managers with monthly JOC meeting preparations, research outliers in financial reports, audit reports for accuracy, assist with follow up items from meetings.