Network Service Consultant

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

📋 Description

• Foster and sustain collaborative partnerships with physicians, hospitals, ancillary providers, and vendors.

• Influence the provider network landscape utilizing objective data and education across various stakeholders, markets, and product lines.

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

• Engage in provider outreach through email, phone calls, in-person meetings, and webinars.

• Evaluate provider efficiencies in relation to the health plan.

• Conduct initial provider orientations alongside ongoing educational outreach.

• Facilitate group training sessions.

• Address provider contract inquiries, investigate issues, and resolve escalated concerns.

• Represent the health plan at functions organized by healthcare associations.

• Participate in regulatory reporting concerning provider networks.

• Keep an eye on competitors and market regulations.

• Assist in strategic positioning to establish and maintain provider networks.

• Help the Credentialing Department obtain challenging documents.

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

• Report directly to the Manager of Network Services.

⛳️ Requirements

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

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

• 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 meticulous attention to detail.

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

• Excellent written and verbal communication skills.

• Proven ability to develop 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 processing and/or coding.

• Established provider relationships in West Virginia.

• Willingness to travel for offsite meetings as necessary.

🏝️ Benefits

• Full-time position with 40 scheduled hours per week.

• Remote work location available.

• Occasional travel may be necessary for offsite meetings.