Network Engagement Specialist

About the role

The Network Engagement Specialist coordinates necessary services for members with out-of-network providers, hospitals, and groups. This role involves overseeing provider communications, issue resolution, case submissions, and closures, as well as managing data exchanges with care partners, local hospitals, and other in- and out-of-network providers. The Specialist builds strong connections between UPN and provider partners to enhance collaboration and service delivery, educates local hospitals and ancillary providers on UPN’s processes, and facilitates efficient routing to in-network providers. The role includes a mix of administrative tasks and project management, with a focus on enhancing member satisfaction and maintaining effective provider relationships.

Responsibilities

• Work closely with in- and out-of-network hospitals, facilities, healthcare providers, and ancillary vendors to coordinate effective care for members based on medical and utilization management guidelines.
• Serve as the primary contact for intake, review, and execution of Letter of Agreements (LOAs) and associated authorizations.
• Intake, review, and closure of grievances by coordinating with internal and external teams, health plans, and providers.
• Reroute and coordinate referrals based on direction from the Medical Director (MD), Associate Medical Director (AMD), and Utilization Management (UM) staff.
• Assist with expedited referrals as designated by MD and AMD by coordinating internally and/or externally.
• Submit referral modification requests as guided by MD and AMD.
• Work with internal teams to schedule primary and specialty appointments as directed by MD and AMD.
• Intake Peer-to-Peer requests and process according to established protocols.
• Maintain ongoing, professional, and effective communication with all providers in UPN’s network.
• Maintain accurate records of errands and vehicle usage.
• Answer UPN customer service phone line to appropriately address and/or reroute inquiries.
• Handle administrative tasks related to provider relations, including documentation, reporting, and follow-up communications.
• Audit Health Plan provider rosters and directories to ensure UPN Network providers are listed accurately; work with the Management Service Organization and Health Plans to address any deficiencies.
• Support providers through the credentialing/re-credentialing process, including addressing provider questions and ensuring timely completion of applications.
• Collaborate with internal and external care partners in the creation and distribution of orientation and educational materials for hospital and ancillary services personnel.
• Build provider awareness and engagement with UPN for potential contract opportunities for ancillary services and hospital partnerships.
• Oversee incoming mail and distribute to appropriate personnel.
• Intake complaints and grievances from government agencies and health plan partners; review, research, and formulate responses in a timely manner.
• Intake and document Medicare Advantage Broker requests for approved UPN information, as well as Health Plan Partner and Medicare Advantage Broker complaints.
• Provide administrative support to the Contracting & Managed Care Officer (CMCO) and MD as needed.
• Serve as an internal UPN provider advocate by communicating key provider pain points and working with stakeholders to support UPN’s contracted ancillary providers.
• Collaborate with Marketing, Sales, Provider Data, Credentialing, Operations, and other teams to coordinate cross-functional in-market activities.
• Work closely with the MD, CMCO, and Provider Relations staff to align initiatives with organizational goals and improve care transitions.
• Ensure compliance with all relevant regulations and organizational policies related to member care and provider relations.
• Track claims erroneously sent to the UPN Office and reroute them to UPN’s Claims team; contact facilities to ensure future claims are sent to the correct address.
• Travel short distances using a company vehicle to pick up supplies, deliver documents, and attend offsite meetings.
• Attend and actively participate in department, program, and employee staff meetings, as well as workshops/seminars to increase skills and knowledge.
• Support the overall needs of the health center by working flexible or extended hours when necessary.
• Maintain confidentiality and abide by HIPAA regulations regarding privacy.
• Display a positive, professional, and respectful demeanor at all times toward employees, peers, professional contacts, and patients.

Requirements

• High School Diploma or GED required.
• Bachelor’s degree in Business, Health Care Administration, Communications, or a related field is preferred; equivalent work experience and education will be considered.
• Completed training program in Medical Assisting from an accredited college is preferred.
• Two (2) or more years of experience in the healthcare industry navigating relationships around providers and insurance networks is preferred.
• Possess a valid CA driver’s license.

Skills

• Bilingual (English/Spanish) is preferred.
• Ability to establish rapport and effective working relationships with providers and health center administrators.
• Excellent communication skills, including negotiation; must be persistent and persuasive.
• Advanced proficiency in various computer applications and exemplary email communication skills.
• Ability to prioritize multiple responsibilities and manage a large workload within budget and timelines.
• Excellent problem-solving skills and self-motivation.
• Ability to develop alternative solutions to problems.
• Ability to prepare clear, concise, thorough, and grammatically correct written reports, letters, memos, and other documents.
• Strong customer service orientation, positive attitude, and highly self-motivated.
• Ability to independently plan, organize, prioritize, schedule, coordinate, and make decisions related to assigned responsibilities.

Pay

The hourly wage range for this position starts at $29.27 an hour, dependent on knowledge, skills, and experience.

Benefits

• Comprehensive medical, dental, and vision insurance with low premium costs.
• Paid time off and paid holidays.
• 401k plan with matching contribution.
• Educational assistance.
• Employee discounts and more.