Network Service Consultant

This is a fully remote position, open to applicants in Virginia, +1 more state.

📋 Description

• Build and nurture collaborative relationships with healthcare providers, including physicians, hospitals, ancillary providers, and vendors.

• Influence the landscape of the provider network using objective data and educational initiatives across various stakeholders and product lines.

• Provide education to providers regarding credentialing, contracting, authorizations, referrals, claims and encounters, grievances and appeals, health education, population health, care management, pharmacy management, electronic health records, health information exchange, data exchange, and regulatory updates.

• Carry out provider outreach through various channels such as email, telephone, in-person meetings, and webinars.

• Evaluate provider efficiencies during their interactions with the health plan.

• Facilitate initial provider orientations and continuous educational outreach.

• Organize group training sessions.

• Assist with inquiries regarding provider contracts, investigate issues, and resolve escalated matters.

• Represent the health plan at healthcare association events.

• Engage in regulatory reporting for provider networks.

• Keep an eye on competitors and market regulations.

• Aid in strategic positioning to develop and sustain provider networks.

• Support the Credentialing Department in acquiring challenging documents.

• Collaborate with Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing, as well as Member and Provider Service teams.

• Report to the Manager of Network Services as a member of the Provider Relations team.

⛳️ Requirements

• Bachelor’s Degree in business or a healthcare-related discipline.

• Fundamental understanding of contracts, Value Based Reimbursement, performance-based provider reimbursement programs, and products related to Commercial, Medicare Advantage, Medicaid, and PEIA.

• Familiarity with regulatory reporting for provider networks, including the WV Department of Insurance, Department of Medicaid/Health Services, and CMS.

• Knowledge of provider quality measurement systems such as Medicare STARS, HEDIS, and PCMH quality programs.

• Strong strategic thinking skills and attention to detail.

• Awareness of federal and state laws, including CMS and BMS regulations.

• Exceptional written and verbal communication skills.

• Proven ability to cultivate and maintain relationships.

• Proficient in Microsoft Office applications.

• Experience with Commercial, Medicare, and Medicaid products.

• Understanding of provider credentialing and data management processes.

• Working knowledge of claims and/or coding practices.

• Established relationships with providers in West Virginia.

• Standard office-environment working conditions.

• Willingness to travel for offsite meetings when necessary.

🏝️ Benefits

• Full-time employment.

• 40 scheduled hours per week.

• Some travel may be necessary for offsite meetings.

• Reasonable accommodations may be provided for individuals with disabilities.