Responsibilities

• Coordinates the company’s provider recruitment and contracting activities and provide orientation to new providers.
• Assists in the development and execution of provider evaluation; credentialing and re-credentialing programs, both short and long term, to ensure the availability of quality health care for members.
• Assists in provider negotiation, research, and establishment of fee schedule to ensure appropriate compensation of providers.
• Collect, collate, analyze and reports provider reimbursement and utilization data for use in contract negotiations and policy creation.
• Conducts provider education on company policies and lead proactive orientation seminars with providers and provider groups.
• Maintains effective control of the member-provider-insurance referral system and the correct implementation of contracts / policies.
• Develop and maintains a provider file, database, directory, and provider relations manual.
• Ensures that provider files, including but not limited to, Provider Directory, Provider Manual, Provider Newsletters, Provider contracts/fees/notices, Provider cost estimates for members, Provider information updates or attestation requests and Provider network status, are released on time and made available in compliance with applicable provider contracts and relevant Federal and State law.
• Ensures compliance with Plan Accreditation requirements for Provider Network Credentialing
• Facilitates system fee configuration and testing

Requirements

• Bachelor’s or Associate's degree in Math, Statistics or related field or equivalent experience
• Minimum of two (2) years’ experience in health insurance is preferred
• Proficient in the use of Microsoft Office (Excel, Word, PowerPoint, Outlook)
• Computer literate (Windows)