Provider Network Representative

3 weeks ago

Albuquerque, New Mexico, United States Innovative Systems Group Full time

Work Location: 5701 Balloon Fiesta Parkway, Albuquerque, NM 87113

Contract: 2025-02-03 to 2025-12-31

Expectation to work a hybrid schedule- 3 days onsite, 2 WFH.

RESPONSIBILITIES:

1. Provide information and assistance needed to resolve problems experienced by practitioners in their various contractual relationships with HCSC, including but are not limited to claims, pricing, or contracts. Assure both parties understand the mechanics of our relationship with these providers and that our various networks are working well for all involved. Record activities in the specific format required by the region and management. Keep management advised of activities and needs accordingly.

2. Assist in providing training and continuing policy education on all facets of operations of HCSC to provider staff and others as needed. Conduct provider servicing and assist in the development and distribution of appropriate training materials, etc., as needed.

3. Submit reports on service and recruiting activities and other items as required by management.

4. Respond to fee requests from providers.

5. Provide ongoing development of database, reports and statistical analyses of managed care networks. Create, modify and maintain new and existing reports to provide accurate information for both internal and external reporting.

6. Assist with the coordination and resolution of systemic problems and claim issues. Identify problem and research the impact and origin for resolution. Report problem to management and coordinate with either internal staff or the provider to assure resolution.

7. Assist with the review of provider directories for the managed care networks.

8. Develop and maintain a good working relationship with Core Services, Local Medical Directors, and other internal departments. Coordinate with various HCSC departments as required for the recruitment, servicing and retention of contracted providers.

9. Establish working relationship with key facilities, physician groups, practice managers, IPAs, PHOs and other essential contacts. Serve as liaison between facilities or provider office staff and various internal departments.

10. Maintain a high level of expertise in pricing arrangements, contract requirements/language, benefits, membership, claims processing, utilization review, etc.

11. Process providers change forms. Maintain tickler system and verify that all changes have been made in the appropriate system.

12. Prepare monthly reports and update provider databases as necessary. Assist with routine and special reporting requirements.

13. Prepare and mail provider orientation packets, provider manuals and application packets.

14. Communicate and interact effectively and professionally.

15. Comply with HIPAA, Diversity Principles, Corporate Integrity, Compliance Program policies and other applicable corporate and departmental policies.

16. Maintain complete confidentiality of company business.

17. Maintain communication with management regarding development within areas of assigned responsibilities and perform special projects as required or requested.

JOB REQUIREMENTS:


• Bachelor's degree OR 4 years of work experience in the health care/insurance industry


• 3 years' experience in Network Management, Credentialing and/or Customer Service.


• Understanding of health care contracts, applications and products.


• Working knowledge of claims processing systems.


• 3 years' experience utilizing a PC.


• Familiar with provider reimbursement methods.

PREFERRED JOB REQUIREMENTS:


• Knowledge of health care policies, products and procedures.


• Excel savvy, customer service skills, MCO experience

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