Provider Network Specialist-Disputes (Remote Option-NC)

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. 

Location:  Remote option;  Available for any of Partners' NC locations

Projected Hiring Range:  Depending on Experience 

Closing Date:  Open Until Filled

Primary Purpose of Position: This position manages provider disputes, sanctions, and terminations and monitors the process for each of those ensuring a high-quality network to serve Partners members.  

Role and Responsibilities: 

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

• Oversees the follow-up and management of the provider dispute resolution process including notification letters of receipt of dispute, tracks timelines, maintains dispute log, conducts complete and thorough investigation of dispute, composes notification letter to provider related to that decision.
• Visits provider agencies to facilitate communication & collaboration as needed;
• Obtains and maintains information regarding provider sanctions, terminations and disputes;
• Completes routine and ongoing contract compliance monitoring to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations;
• Interprets audit results, 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 through the Network Management Committee;
• Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the Member Engagement Department, the Program Integrity Department, the Quality of Care Committee, Network Management Committee or as indicated by another agency or departmental identified need;
• Serves as a subject matter expert and as a resource to other departments within the LME/MCO on provider issues specifically related to provider terminations, sanctions and dispute information when appropriate;
• Manages notification and tracking of provider contract terminations; 
• Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed;
• Monitors all NMC issued sanctions for all providers;
• Maintains a log of all Medicaid and IPRS procurement contract terminations;
• Participates in oversight and monitoring reviews of the MCO including but not limited to NCQA and EQR reviews as appropriate.
• Interpreting and assisting in developing and maintaining policies 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 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 mental health, public health, social work, psychology, education, sociology, business or public administration and two (2) years of experience in a community, business, or governmental program in health-related fields, social work or education including experience in network operations, provider relations and management experience. 

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

Licensure/Certification Requirements: