Network Service Representative jobs in Pennsylvania

Company :

Job Description : 

JOB SUMMARY

*** Due to Department of Defense (DOD) contract requirements, the incumbent who fills this position must be a US citizen and must also pass a background check. ***

This job services United Concordia Dental's (UCD’s) clients by recruiting, training and servicing quality dental networks in assigned territory in a remote and mobile work environment.  Manage network contracts including negotiations, contract development/renewal and financial reimbursement.  Meet with dentists and office personnel to act as the intermediary between the organization and UCD.  Respond to contractual and payment issues both internally and externally. Ensure compliance with contractual terms through regular on-site audits.  Apply an active role in network management, training, monitoring and enforcement of company policies and procedures while increasing provider efficiencies.

ESSENTIAL RESPONSIBILITIES

• Identify and initiate contact with prospective providers.  Develop and follow up on leads in an established time frame, while incorporating a sound business plan strategy to support and execute recruitment efforts that include existing and prospective client needs and provider resignations/terminations.  Customize participating dental agreement forms for execution, analyze provider changes, facilitate provider file updates and draft confidentiality agreements.  Monitor financial performance of contracts by tracking utilization and competitive environment, including group specific performance guarantees.  
• Analyze and develop network retention strategies for follow up services to providers by establishing and maintaining contact and rapport with dental staff members, office managers, insurance coordinators, hygienists and dentists throughout an assigned territory by scheduling face-to-face meetings with dental offices.  Formally present and effectively communicate UCD's administrative and claim guidelines and policies, benefits of participation, fee schedules, plan designs, competitive position, product development, network options, strategic partnerships, utilization review, local/national client demographics and dentist distribution.  Interpret and articulate contractual language and address questions regarding participation with providers, network share/leasing arrangements, opt in/out options, reimbursement methods, compensation models, including pay for performance and value added benefits.  Meet with all identified practices in assigned territory to review practice financial and quality performance.
• Perform effective on-site visits through educating providers on the financial advantages and marketing incentives of participation.  Train dental office staff on the use of automated services to ensure they utilize various means of automated communication, as well as, claims and electronic data interchange and electronic funds transfer.   Collaborate with sales and customer service to respond to client/broker/member inquiries regarding provider contract, claim/member issues or provider file/record/directory discrepancies.  Consult with dental director/dental advisers regarding clinical-related questions and policies, as well as, current dental terminology (CDT) changes, to resolve provider inquiries within a mutually agreed timeframe.
• Act as subject matter expert with recommendations and data supporting development of network and sales strategy and support of leasing contract negotiation. Develop and maintain leasing revenue targets.  Update network lease risk strategy in response to all market changes.
• Communicate and maintain effective working relationships both internally and externally (providers, dental industry, organized dentistry and dental consultants) keeping management informed on related healthcare industry issues/topics.  Support competitive position in the marketplace by staying abreast of changes to the business climate. Monitor provider reimbursement methods and PPO/DHMO/EPO network models and communicate changes to provider community and leadership team.  
• Develop and manage process improvement initiatives designed to maintain URAC accreditation of all network practices associated with government programs using continuous quality improvement principles.  Conduct, collect and analyze data from office site visits and reviews to continually improve the care and service to members and provide recommendations to internal customer supporting quality improvement programs.  Train dental office staff and providers on all updates to quality assurance guidelines, with state and local regulations and URAC accreditation requirements.  Conduct audits as needed.
• Other duties as assigned or requested.

EDUCATION

Required

• High School Diploma/GED

Preferred

• Bachelor's Degree - Business

EXPERIENCE

Required

• *** Due to Department of Defense (DOD) contract requirements, the incumbent who fills this position must be a US citizen and must also pass a background check. ***
• 3 - 5 years of experience in the healthcare/insurance industry or professional experience in presenting concepts and influencing others in varying audiences

Preferred

• 3-5 years of experience as Dental Office Manager or Dental Hygienist

SKILLS

• Written and oral communication skills
• Time management and organizational skills
• Knowledge of ADA/CDT codes and general dental terminology
• Negotiation skills
• Ability to analyze situations, determine points of relevance and proper course of actions

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement : This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times.  In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy. 

Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.

Pay Range Minimum:

Pay Range Maximum:

Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations.  The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.

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