Provider Network Specialist-Maintenance (Remote-NC)

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
• Public Service Loan Forgiveness Qualifying Employer

See attachment for additional details. 

Office Location:  Flexible for any of our office locations; Remote option in NC
Projected Hiring Range:  Depending on Experience
Closing Date:  Open Until Filled

Primary Purpose of Position: This position assists in the enrollment, maintenance, development and management of the Provider Network for members who have been identified as having mental health, substance use or intellectual development disability needs.

Role and Responsibilities:

A Provider Network Maintenance Specialist’s primary duties may be one or more of the following:

• Responsible for reviewing,monitoringand ensuring compliance with facility licensure, national accreditation requirements, clinical coveragepoliciesand other requirements related to the provision of behavioral healthservices;
• Responsible for receiving, reviewing,analyzingand entering time sensitive and confidential providerinformation;
• Responsible for ensuringthat providers are properly enrolled in NC Tracks prior to enrolling them into the system.
• Demonstrates understanding of Tailored Plan and Medicaid Direct health plans
• Responsible for managing,trackingand filing informationsubmittedto and information received from providers related to ongoing maintenance of provider enrollment andcontracting;
• Responsible for managing, processing,trackingand filing requests from providers to join the network and requests from providers to make changes to theircontracts;
• Responsible for regular follow-up of status ofsubmittedrequests to join the network and provider maintenancerequests;
• Responsible for resolving issues and supporting providersregardingtheir requests to contract with or make changes to their contract withPartners;
• Responsible for monitoring and follow-up associated with the provider enrollment file and the provider networkfile;
• Participates in performance improvementactivities;
• Receive and process requests for access to Partners Provider Portal
• Composes letters,memosand emails to internal and external contacts.
• Researchesquestions related to joining the Partners provider network and/or change requests and responds to internal and external contactsregardingconcerns related to delays and inconsistencies in information;
• Demonstrates the ability to communicate professionally and clearly in both verbal and written form both internally andexternally;
• Monitors and updates provider information asrequired;
• Accurately and clearly documents process steps,datesand work status.
• Verifies providers meet the requirements to provide services in the Network according to parameters determined for qualifications and needs of theNetwork;
• Interprets audit results,identifiestrends/patterns thatimpactservice/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree ofquality;
• Collaborates with Quality Management Department, Program Integrity Department, Provider Network Relations,Member Engagement,andCommunity Engagementto collect information related to quality of care for the purpose of enrollment ofproviders; 
• Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by theMember EngagementDepartment, the Program Integrity Department, theQuality of CareCommittee, Network Management Committee,or asindicatedby another agency or departmental identifiedneed;
• Serves as a resource to other departments within the LME/MCO on provider-relatedissues;
• Serves as a liaison with other departments within the LME/MCO and with various NC DHHS Departments, per rule requirements, to coordinate Specialist’s activities andfindings;
• Participates in Provider Forums as requested and provides technical support andassistanceto Provider Councils asneeded;
• Participates in oversight and monitoring reviews of the MCO including but not limited to EQR and NCQA reviews asappropriate;
• Responsible forinterpreting andassistingin developing andmaintainingpolicies and procedures.

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 andproficiencyin Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint
• Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws,rulesand 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 toestablishrapport andmaintaineffective working relationships
• Ability to act with tact and diplomacy in all situations
• Ability tomaintainstrict confidentiality in all areas of work
• Ability to analyze and interpret policy and procedural guidelines and to resolve problems and questions, independently
• Ability to complete non-routine activities and tasks that require deviation from established procedures which includes the ability to choose theappropriate courseof action and recognize the existence of and differences among situations
• Ability to use initiative and judgment in resolving problems not covered byestablishedpriorities or prior experience

Education/Experience Required: Bachelor’s Degree and two (2) years of credentialing, provider enrollment, auditing or monitoring experience in MH/SU/I-DD. Must have ability to travel. MUST reside in North Carolina.

Education/Experience Preferred: N/A

Licensure/Certification Requirements:  N/A