Provider Network Specialist jobs in Pembroke Pines, FL

Health Network One is the leader in managing specialty healthcare networks. Founded in 1999, we are a rapid growing, private equity-backed company that delivers cost savings to our health plan customers, world-class service to our provider networks, and access to quality healthcare for health plan members.

On behalf of our health plan clients, we manage the entire network value chain, including utilization management, claims, and provider management. Our specialty networks exceed 10,000 providers and include outpatient therapy, dermatology, podiatry and more. Today we operate in four states and are expanding into four more; in total, we cover more than 5,000,000 lives.

Position Summary:

Interacts with and discusses contract and credentialing with physicians, specialist, ancillary providers and hospitals. Performs revenue analyses for the Provider Relation/ Network Department.

Essential Duties and Responsibilities

• Target and/or follow-up with potential providers to establish contractual agreements.
• Interacts with provides regarding all contract matters for HN1 including any necessary documentation. (i.e. credentialing, applications, W-9, PIP, etc)
• Recruits and contracts physicians, specialists, ancillary providers and hospitals for HN1.
• Responds to provider inquiries regarding contract matters, provider networks issues and HN1 operations.
• Works with contracted providers to help integrate their services into the overall care delivery network.
• Researches and solves any questions or concerns that providers, external provider representatives, Health Plans and other internal departments may have.
• Analyzes, prepares, maintains and distributes various departmental reports, including specialized reports for providers or networks; HN1 quarterly provider bulletins; various presentations and custom reports requested by Senior Management.
• Organize, develop and execute provider outreach projects.
• Researches providers utilization data with reference to negotiating new rates and utilization performance of individual providers and the network.
• Maintain lines of communications with all internal departments and with all participating providers in enlisting their assistance in referring potential providers in the Network.
• Attend corporate and departmental meetings to assist with company projects and goals (i.e.
• URAC, Executive Committee meetings, etc.)
• Ensures compliance with and/or adheres to company HIPAA policies and procedures.
• Ensures integrity of data entered into company systems and databases.
• Manage the normal office activities for the Network Department to include but not limited to:
• Maintains and updates physician files.
• Supports Credentialing Department by assisting with the collection of physician credentials for re-credentialing purposes.
• Evaluates claim data on recently contracted providers, ensuring contract is profitable for Company.

Required Education and Experience

• High School graduate or equivalent (GED); and previous health care experience.
• Bilingual is required (Spanish/English)
• Knowledge of physician office procedures.
• Knowledge of medical terminology, CPT coding, billing procedures.
• Strong Organizational skills.

Job Type: Full-time

Pay: From $18.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Vision insurance
• Work from home

Weekly day range:

• Monday to Friday

Work setting:

• In-person

Work Location: In person