Provider Network Specialist-Hospital (Remote Option)

Competitive Compensation & Benefits Package!  

Position eligible for – 

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs

See attachment for additional details. 

Office Location:  Negotiable for any of our office locations; Remote Option Available 
Projected Hiring Range:  Depending on Experience
Closing Date: Open Until Filled

Primary Purpose of Position: This position assists in the development, support, and management of the provider network for both physical health and behavioral health. This position is expected to build and sustain strong working relationships with cross functional departments, physical health plan partners, and both behavioral and physical health providers which include hospital systems. This role requires active participation in provider collaboratives to include providing strategic education on the special needs of the enrollees, a comprehensive understanding of the contract, and serves as a liaison with other Partners’ health plan partners that the provider works with.  

Role and Responsibilities:   

The Provider Network Specialist’s primary duty may be one or more of the following:

• Actively facilitates hospital collaboratives and meetings with identified hospital and health systems to include, but not limited to,  Atrium, Western Regional, Novant Health, Caromont, etc. 
• Participates in Partners crisis collaboratives;
• Participates in Hospital related Timely Follow Up meetings;
• Coordinates with all relevant departments within Partners or stakeholders external to Partners and/or delegated partners regarding bi-annual Provider Manual updates/publishing;
• Coordinates with relevant departments within Partners regarding updating  the Hospital Behavioral Health Instructions and with relevant partners for physical health hospital updating of information  in the Partners Provider Manual;   
• Participates in community collaboratives related to health systems and hospital inpatient and ED activities; coordinates with health systems and hospitals to ensure provider relationship engagement and success. 
• Establishes and maintains regular contact with each of the contracted hospitals and health systems in the Partners provider network for Medicaid Direct and Tailored Plan products. This may include on-site visits to the facilities as needed to ensure ongoing collaboration and compliance with regulations; 
• Educates and collaborates with each hospital/health system regarding policy and procedure changes that potentially impact the hospital/healthcare systems;
• Completes  contract compliance monitoring as needed or requested to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations
• Identifies trends/patterns that impact service/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree of quality;
• Maintains NC Tracks Log-In and assists with interpretation of enrollment/credentialing of hospitals/health systems inside NC Tracks;
• Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the various departments and committees as needed. Serves as a resource to all other departments within the LME/MCO on hospital/health system related issues;
• Actively seeks to increase participation through increasing the number of in-network hospitals/healthcare systems to better support Partners members;   
• Participates in Provider Forums as requested and provide technical support and assistance to Provider Councils as needed; 
• Interprets and assists in developing and maintaining policies and procedures;
• Participates in oversight and monitoring review of the MCO including but not limited to URAC, Mercer and EQR as appropriate; 
• Facilitates rate requests and updates to contracts for assigned providers as requested.

Knowledge, Skills and Abilities: 

• Considerable knowledge of the laws, regulations and policies that govern the program
• Exceptional interpersonal and communication skills
• Strong problem solving, negotiation, arbitration, and conflict resolution skills
• Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint
• Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws, rules and regulations to various situations; to apply regulations and policies for maintenance of consumer medical records, personnel records, and facility licensure requirements
• Ability to make prompt independent decisions based upon relevant facts
• Ability to establish rapport and maintain effective working relationships
• Ability to act with tact and diplomacy in all situations
• Ability to maintain strict confidentiality in all areas of work

Education/Experience Required: Bachelor's degree in health care administration, business administration, accounting, finance, or human services, and two (2) years of experience in provider network relationships or engagement, preferably healthcare systems including but not limited to hospital systems, health care insurance or other health care delivery settings. A combination of relevant experience and education may be considered in lieu of a bachelor’s degree. Must be able to travel as needed to perform job duties. 

Other Requirements:

NC residency is required. 

Must have ability to travel.

Education/Experience Preferred: Master’s Degree with clinical licensure preferred.

Licensure/Certification Requirements:  None