Provider Network Management Specialist 2
4 weeks ago
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Job Title:
Provider Network Management Specialist 2
Department:
OSU Health Plan | Medical ManagementScope of Department
The Provider Network Management department evaluates, initiates, and maintains the provider relationships for The OSU Health Plan provider network and external business provider networks, including but not limited to, Ohio PPO Connect. The department manages activities related to system and provider contracting, network and information management, and credentialing. Team members negotiate contract terms and ensure regulatory, business, and contract requirements are met. Responsibilities of the team include the development and support of statewide provider relationships, provider-related financial and quality analysis, network configurations, claim reimbursements, and other activities in support of provider networks. The Provider Network Management Department serves approximately 150,000 lives and is responsible for greater than $300 million in medical spend through the university’s third party administrator as well as partners with external lines of business to implement customized provider networks that optimize access, cost, and quality.
Scope of Position
This position serves as a Provider Credentialing/Data Specialist on the health plan Provider Network Management team. The Provider Credentialing/Data Specialist reports to the Director of Provider Network Management and works collaboratively with providers, clients, third party administrators, directors, managers, and other provider network management team members to optimize access, cost, and quality within our provider networks. The Provider Credentialing/Data Specialist serves as a primary point of contact for ensuring all network providers have accurate and comprehensive provider data information. The Provider Credentialing/Data Specialist collaborates with the Director of Provider Network Management and the provider relations team to credential/re-credential providers, investigate claims payment concerns, resolve provider inquiries, and maintain all provider contact and claims processing information.
Position Summary
The Provider Credentialing/Data Specialist manages the health plan’s provider service operations. The specialist is the primary point of contact for provider, client, and third party administrator inquiries regarding credentialing, re-credentialing, and provider name, reimbursement, TIN, and location information. This position collaborates with Provider Network Management team members, clients, third party administrators, and providers to investigate and resolve provider data discrepancies for web updates, fee schedules, network tiering, and provider demographics and verifies contract information for clients, third party administrators, and providers. The specialist must be able to exercise superior critical thinking and problem solving to research and resolve complex claims payment issues in an accurate and timely manner.
The Provider Data/Credentialing Specialist manages the health plan’s credentialing and provider information databases. The specialist manages the processes to verify credentials of new and continuing network providers ensuring NCQA standards are met. The position prepares new provider welcome letters, credentialing reporting for the Health Plan Quality Improvement Committee, and licensure actions for the Medical Director. The specialist manages all provider changes (tax identification numbers, name changes, physical address changes, remit changes, etc.) in an accurate and timely manner to avoid claim issues. The position performance quality assurance of all provider databases.
The Provider Data/Credentialing Specialist makes recommendations for new and revised credentialing/re-credentialing policies and procedures. The position creates rosters of group information to include practitioner(s), addresses and effective dated and reviews TPA reports regarding retro adds/changes/removals, groups not changed, and appropriateness of claims payment/non-payment reasoning. The specialist handles provider grievances and service issues in conjunction with other departments and third party administrators.
Minimum Qualifications
Bachelor's degree and 2 years of relevant experience.
Explore our extensive benefits
.
Work-life: Flexible and remote work arrangement opportunities where applicable, childcare program, and access to educational, athletic and cultural events.
Retirement: State pension and alternative options with competitive employer contributions, as well as optional supplemental plans.
Health: Medical, dental, vision and prescription coverage, life insurance, flexible spending accounts and wellness programming.
Time off: Paid vacation and sick time, parental and medical leave plus 11 paid holidays. Short and long-term disability options also available.
Financial: Tuition assistance for employees and their dependents, adoption assistance and discounts with preferred vendors and university partners.
Wellness: Lifestyle spending account, employee assistance program, health reimbursement account, and employee wellness program.
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