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North East Medical Services · 1 month ago

PROVIDER NETWORK COORDINATOR

Burlingame, CA

Full-time

Onsite

Entry, Mid Level

$39/hr - $45/hr

2+ years exp

North East Medical Services is seeking a Provider Network Coordinator (PNC) to support and maintain service relationships within the MSO provider network. The PNC will focus on provider credentialing and data management, ensuring compliance with various health regulations and facilitating communication between providers and health plans.

Hospital & Health Care

H1B Sponsor Likely

Responsibilities

Serve as point of contact between NEMS organization, MSO network providers, Health Plans and other community partners to support credentialing and provider data maintenance

Assist with the development of written communications for general NEMS MSO notifications, provider newsletter, MSO website, and maintaining provider on-line directory and tools/resources

Responsible for the initial credentialing and re-credentialing activities for new and recertified providers, including licensure verifications, follow up on completion of applications and/or missing/unclear data, according to Health Plan, State, Federal and NCQA requirements

Responsible for inputting and maintaining credentialing information for physicians and organizations, utilizing monitoring reports to tracking for physicians’ re-credential status, quality assurance information, verification of sanctions, and incident investigation status

Coordinate and facilitate the NEMS/MSO Credentialing/Privileging Committee meeting and follow up on action requests by the Committee

Be the point of contact for credentialing denials, provider complaints and/or appeals about credentialing

Carry out monthly monitoring activities to ensure NEMS MSO network providers are in compliance

Coordinate with contracted entities for Credentialing sub-delegation ongoing reports, rosters, and monitoring

Coordinate with contracted Health Plan(s) for annual delegation audits, and any other audits conducted by DHCS/DMHC/CMS as applicable. This includes preparing audit files and universes

Ensure all NEMS systems containing provider data are accurate and updated accordingly. Also communicate provider changes to other internal teams, as appropriate

Communicate with contracted Health Plans to report new, updated, or terminated physician and practice information as required per SB137

Submit accurate and complete provider rosters to contracted health plans based on contractual requirements. Update contracted health plan on provider/adds/terms and changes, as needed, between roster submissions

Research and understand complex issues raised by physician practices, and/or health plan partners, coordinate with other internal teams for follow up activities and resolution

Identify and research a variety of issues related to provider credentialing, compliance, and operational issues, utilizing various sources, including but not limited to current contracts, publications, websites, and provider notifications

Play an active role in supporting new team members and assist with trainings

Perform other duties as assigned

Qualification

Provider credentialingHealthcare complianceData managementMedicare knowledgeManaged care experiencePC literacyFluent in other languagesFluent in EnglishCommunication skillsProblem-solving skillsOrganizational skills

Required

BA/BS degree; Associate Degree may be considered with relevant, equivalent work experience

2-3 years work experience in healthcare setting in the areas of provider relations, claims, or utilization management is preferred

Knowledge of Medicare and/or Medi-Cal managed care program and/or other state-sponsored program is a plus

Prior managed care experience with knowledge of CMS/DHCS health policy is a plus

Superior ability to communicate (spoken and written) effectively with a variety of professionals, including physicians and other healthcare providers, business administrators and contracting managers, billing and revenue cycle agencies

Must be PC literate - Strong Excel, Word, Power point, and Outlook skills

Knowledge of community resources and culture is a plus

Detail-oriented and organized with the ability to interpret DHCS policy letters and make decisions

Good organization and problem-solving skills

Ability to self-manage and work with multiple departments within the organization and external clients

Must be able to fluently speak, read and write English

Preferred

2-3 years work experience in healthcare setting in the areas of provider relations, claims, or utilization management is preferred

Knowledge of Medicare and/or Medi-Cal managed care program and/or other state-sponsored program is a plus

Prior managed care experience with knowledge of CMS/DHCS health policy is a plus

Knowledge of community resources and culture is a plus

Fluent in other languages are an asset

Benefits

Competitive benefits, including free medical, dental and vision insurance for employee, spouse and/or children

Company contribution to 401(k)

Company

North East Medical Services

North East Medical Services (NEMS) is one of the largest community health centers in the United States targeting the medically underserved Asian population.

Founded in 1968

San Francisco, CA, US

501-1000 employees

https://www.nems.org/

H1B Sponsorship

North East Medical Services has a track record of offering H1B sponsorships. Please note that this does not guarantee sponsorship for this specific role. Below presents additional info for your reference. (Data Powered by US Department of Labor)

Distribution of Different Job Fields Receiving Sponsorship

Represents job field similar to this job

Trends of Total Sponsorships

2025 (20)

2024 (7)

2023 (8)

2022 (5)

2021 (1)

2020 (1)