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Company

Arkansas Blue Cross and Blue Shield · 1 day ago

Provider Network Specialist I

Little Rock, AR

Full-time

Remote

Entry Level

2+ years exp

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Financial ServicesHealth Care

No H1B

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Responsibilities

Analyzes and maintains thorough knowledge of products, complex systems, data elements, and information from multiple external sources to accurately gather data regarding malpractice, legal, license issues, and hospital privileges while providing front facing phone and electronic correspondence customer service from receipt of internal and external mail.

Meets corporate URAC guidelines while maintaining performance levels based on established department standards for production and quality.

Oversees credentialing, maintains provider files, contracts, provider data maintenance, and communications. Ensures providers meet standards, contracts are upheld, and data is accurate.

Performs all provider related administrative tasks such as provider enrollment, data maintenance, provider number assignment, credentialing, correspondence, document preparation, etc. Thorough documentation of actions, records and/or correspondence is required.

Performs other duties as assigned.

Reacts and adapts to changes in network management strategies to be aware that research findings have the potential to significantly impact Enterprise operations.

Responsible for initiating and maintaining good relations with providers and their staff, PHOs, hospitals, collaborative health initiatives, and other company personnel (especially the Regional Offices, claims divisions, and customer service areas).

Responsible for maintaining an operational knowledge of all commercial provider networks; including lines of business and custom networks, ABCBS, HA, and BAA coverage and guidelines, contracting requirements and a detailed knowledge of credentialing standards as well as knowledge of divisions and subsidiary operations. Applies knowledge in decisions necessary for assignment of provider numbers, credentialing of providers, and determining whether admission to networks is appropriate.

Responsible for obtaining/maintaining accurate, thorough, and up-to-date records on the credentials, qualifications, demographics and reimbursement of all assigned providers.

Sends correspondence to providers, PHO liaisons, and facilities to obtain and gather necessary information to be submitted to committee.

Stays up to date on provider academic training programs, specialty and sub-specialty qualifications, board certification processes, general practice patterns, medical mal-practice insurance, primary source verification processes, licensing boards, accreditation organizations, National Practitioner Data Bank, Health Integrity Practitioner Data Bank, and AR State Medical Board Centralized Credentials Verification Service.

Works collaboratively with various internal departments, external resources, and/or providers to resolve issues, while keeping leadership informed of progress and resolutions.

Qualification

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MS Office SuiteCredentialingProvider ContractsHighly OrganizedTaking Initiatives

Required

High School diploma or equivalent.

Two (2) years of operations support experience related to provider networking, claims processing, customer service, membership enrollment or related experience.

Proficiency working with MS Office Suite, such as Word and Excel

Interpersonal Communication

Verbal Communication

Written Communication

Credentialing

Provider Contracts

Problem Solving

Decision Making

Microsoft Office

Detail Orientation

Taking Initiatives

Self-Motivation