Provider Network Specialist

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Job Description Summary:

Key individual in the Network Management department of the OhioHealth Clinically Integrated Network (CIN). This position is in place to manage and support the relationship between the physicians and payers in our network, managing current contracts on the physicians and the management of claims complaints and quality of care complaints. The handling of recruitment in areas that are identified as having a business need, and negotiations of their fee schedules. Audit payer rosters, update credentialing software (Cactus) after committee approval and verify and audit practice and demographic information is correct for directory, website distribution, and claims payment. This position is the Liaison between departments within OhioHealth for contracting and network product questions/issues.

Responsibilities And Duties:

 
Serve as strategic partner to providers and CIN payers (15%):
●                 Provide services to provider network offices for issues related to claims payment, products descriptions, education/training of staff, fee schedules, complaints, termination of contracts, and verifying all minimum requirements to obtain a contract are maintained.
●                 Assist in managing, maintaining, and auditing functions related to provider databases for physicians and claims payment to ensure demographic information is correct.   
●                 Participate in collaborative work initiatives with other OhioHealth departments to enhance organization efficiency and effectiveness. Helping to create and improve workflow processes and procedures.
Issue mitigation/maintain high customer experience with external and internal customers (70%):
●                 Respond to external and internal customers’ inquiries, and email according to departmental standards.
●                 Provider follow-up and feedback to appropriate departments on provider issues.
●                 Maintain professional comportment with all customers.
●                 Follow-up with providers, or internal customers within two business days, or agreed upon date with those parties, on unresolved issues/questions.
Network Management Activities (15%):
●                 Assist in provider recruitment for network participation.
●                 Market analysis: receive, review and understand the make-up of the network (CIN) as it relates to recruitment and basic understanding for communication.
●                 Assist in provider network retention, to meet or exceed department goals.
●                 Audit provider data to ensure data accuracy.
●                 Communicate benefits of network participation to current and prospective network providers.
●                 Assist current and prospective network providers in credentialing and re-credentialing process.

Minimum Qualifications:

Bachelor's Degree

Additional Job Description:

• Degree or 5 years applicable experience in Health Insurance / Health Benefit Plan experience, or Healthcare provider experience (billing, claims, authorization, provider network relations, etc.),
• Clear and concise verbal, written, eye contact, facial expression, and body language communication skills.
•   Attention to detail in practice.
• Active listening skills.
• Excellent documentation skills of customer needs, issues, problems.
•  Capability and use of qualifying skills regarding customers’ needs, issues, problems and getting their agreement on   the items, as well as the timeline for health plan response(s).
• Problem solving skills, as necessary, performed either individually, or in collaboration with others support and assistance.

SPECIALIZED KNOWLEDGE

• Use of Microsoft office products, including but not limited to Word, Excel, Outlook (email, calendar, and contacts), and PowerPoint.

DESIRED ATTRIBUTES

• Experience with Ohio Medicaid's PNM system desired.

Work Shift:

Day

Scheduled Weekly Hours :

40

Department

Credentialing

Join us!
... if your passion is to work in a caring environment
... if you believe that learning is a life-long process
... if you strive for excellence and want to be among the best in the healthcare industry

Equal Employment Opportunity

OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all person in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment 

Remote Work Disclaimer:

Positions marked as remote are only eligible for work from Ohio.