PROVIDER NETWORK COORDINATOR

About the role

The Provider Network Coordinator (PNC) supports, develops, and maintains service relationships with all participants (physicians, hospitals and health systems, providers, and administrators) of the MSO provider network. The primary focus is on timely completion of provider credentialing and re-credentialing activities, according to Health Plan, State, Federal, and NCQA requirements.

Responsibilities

• Serve as the point of contact between NEMS organization, MSO network providers, Health Plans, and other community partners to support credentialing and provider data maintenance.
• Aid in the development of written communications for general NEMS MSO notifications, provider newsletters, MSO website, and maintaining provider online directory and tools/resources.
• Initiate credentialing and re-credentialing activities for new and recertified providers, including licensure verifications, follow-up on completed applications and/or missing/unclear data, according to Health Plan, State, Federal, and NCQA requirements.
• Input and maintain credentialing information for physicians and organizations, using monitoring reports to track physicians' re-credential status, quality assurance information, verification of sanctions, and incident investigation status.
• Coordinate and facilitate the NEMS/MSO Credentialing/Privileging Committee meetings and follow up on action requests by the Committee.
• Be the point of contact for credentialing denials, provider complaints, and/or appeals about credentialing.
• Carry out monthly monitoring activities to ensure NEMS MSO network providers are in compliance.
• Collaborate with contracted entities for Credentialing sub-delegation ongoing reports, rosters, and monitoring.
• Coordinate with contracted Health Plans for annual delegation audits and any other audits conducted by DHCS/DMHC/CMS as applicable, including preparing audit files and universes.
• Communicate provider changes to other internal teams, as appropriate.
• Communicate with contracted Health Plans to report new, updated, or terminated physician and practice information as required by SB137.
• Submit accurate and complete provider rosters to contracted health plans based on contractual requirements.
• Update contracted health plan on provider/adds/terms and changes, as needed, between roster submissions.
• Research and understand complex issues raised by physician practices, and/or health plan partners, coordinating with other internal teams for follow-up activities and resolution.
• Identify and research a variety of issues related to provider credentialing, compliance, and operational issues, utilizing various sources, including but not limited to current contracts, publications, websites, and provider notifications.
• Support new team members and assist with trainings.
• Perform other duties as assigned.

Qualifications

• Bachelor's degree (BA/BS) or Associate Degree with relevant, equivalent work experience.
• 2-3 years work experience in healthcare settings in the areas of provider relations, claims, or utilization management.
• Prior managed care experience with knowledge of CMS/DHCS health policy.
• Superior communication skills (spoken and written), especially with professionals such as physicians and other healthcare providers, business administrators, and contracting managers.
• PC literacy - Strong skills in Excel, Word, PowerPoint, and Outlook.
• Detail-oriented and organized with the ability to interpret DHCS policy letters and make decisions.
• Good organizational and problem-solving skills.
• Ability to self-manage and work with multiple departments within the organization and external clients.
• Fluency in English, with other language skills being an asset.

Benefits

• Competitive benefits package, including free medical, dental, and vision insurance for employee, spouse, and/or children; and company contribution to 401(k).