Provider Network Specialist jobs in Cuyahoga Falls, OH

Summary :

Responsible for the daily operations of the provider maintenance team to develop, manage and monitor processes and procedures that support the provider configuration, set-up and contract execution/maintenance processes for in-network providers. Monitors provider network to ensure SummaCare is in compliance with all state, federal and other regulatory requirements. Manages and supports Sales initiatives through the RFP process.

Formal Education Required :
a. Bachelor's degree or equivalent combination of education and/or experience

Experience and Training Required :
a. Six (6) years’ experience in managed care environment to include;
i. Experience or working knowledge of federal, state and local regulations that pertain to credentialing, contracting, Provider program licensing and payment regulations and experience researching/interpreting regulatory issues
ii. Experience with answering RFP’s and sales initiatives from a provider network perspective.
iii. Experience working with providers preferred.

Other Skills, Competencies and Qualifications:
a. Working knowledge of provider configuration and implementation
b. Working knowledge of network adequacy reporting for provider network filings
c. Monitors contract templates to ensure SummaCare is in compliance with federal, state, local and other regulatory requirements.
d. Vendor Management/implementation
e. Network Accuracy
f. Population Specific Competency: Ability to effectively interact with patients/customers with the understanding of their needs for self-respect and dignity

Level of Physical Demands:
a. Sedentary: Exerts up to ten pounds of force occasionally and/or a negligible amount of force frequently.

The salary range on this job posting/advertising is base salary exclusive of any bonuses or differentials. Many factors, such as years of relevant experience and geographical location are considered when determining the starting rate of pay. We believe in the importance of pay equity and consider internal equity of our current team members when determining offers. Please keep in mind that the range that is listed is the full base salary range. Hiring at the maximum of the range would not be typical.