Provider Network Compliance Specialist

Note, this is a remote opportunity in Ohio. Ohio candidates p referred.

Founded in 1934, Medical Mutual is the oldest and one of the largest health insurance companies based in Ohio. We provide peace of mind to more than 1.

2 million members through our high-quality health, life, disability, dental, vision and indemnity plans. We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement, and individual plans.

Ensures compliance with all statutory, regulatory, program, and accreditation requirements for each of the Company's provider networks.

Acts as the Subject Matter Expert (SME) for the department and accordingly interprets new or updated regulations and develops, enhances, and implements any necessary policies and procedures.

Educates, supports, and collaborates with both internal and external business partners in executing processes that meet all requirements.

Responsibilities

Maintains responsibility for and manages various activities to comply with Medicare Advantage (MA) and Qualified Health Plan (QHP) regulations, which may include, but are not limited to : First Tier, Downstream and Related Entity Oversight - annual attestation project from start to finish including a review / update of the attestation form and resource / educational materials, development of a communication plan, remediation plan for a provider's non-compliance, as well as training of the Provider Contracting staff, Provider Payments - quarterly MA Health Professional Shortage Area bonus payments, as well as ad-hoc claim underpayment / overpayment corrections (re-openings), Inquiries Concerning Providers - daily monitoring of the CORS system for inquiries regarding MA providers created by Customer Care (on behalf of the member), Appeals & Grievances, MA Sales, Care Management, Clinical Quality, etc.

and routes cases to the appropriate Contracting region for resolution. Tracks timeliness of resolution, generates and distributes weekly report to Contracting leadership, Tracks receipt of all MA Health Plan Management System (HPMS) memos and Final Letters to Issuers in the Federally facilitated Exchanges (QHP) received from CMS.

Reviews memos, determines policies, procedures and departments that may be impacted, and performs the following as applicable : updates Provider Manual, creates Provider newsletter article, brochures, flyers;

develops or revises internal policies and procedures. Updates / educates applicable internal staff quarterly or urgently if warranted.

• Develops, reviews and updates department policies and procedures. Provides onboarding and annual training to provider network management staff.
• Contributes to ensuring compliance with NCQA accreditation and the Network Management standards. Monitors and reports on commercial and Exchange provider network availability standards.

Provides quantitative and qualitative analysis for out-of-network claims reports. Identifies and works collaboratively with internal business partners to resolve identified network deficiencies.

Assists the provider termination process to comply with all applicable requirements which includes, but is not limited to, responsibility for member notification letters, continuing care information, reporting, and maintenance of SharePoint site documentation.

Networks included in the process may involve commercial networks, including the national networks; as well as the Exchange (QHP) and MA networks.

Performs other duties as assigned.

Qualifications

Qualifications

• Bachelor's Degree in Business or Health Care Administration or related field.
• 3 years progressive experience in provider network relations, health plan accreditation, or compliance.
• Experience in health plan government programs (Medicare, Medicaid) a plus.
• Strong knowledge of health insurance operations.
• Strong knowledge of CMS regulatory requirements and NCQA standards with the ability to interpret and apply the fundamental concepts to Company operations.
• Strong knowledge of Plan / Provider Collaboration.
• Intermediate Microsoft Office skills (Word, Excel, and PowerPoint).

Medical Mutual is looking to grow our team! We truly value and respect the talents and abilities of all of our employees.

That's why we offer an exceptional package that includes :

A Great Place to Work :

• We will provide the equipment you need for this role, including a laptop, monitors, keyboard, mouse and headset.
• Whether you are working remote or in the office, employees have access to on-site fitness centers at many locations, or a gym membership reimbursement when there is no Medical Mutual facility available.

Enjoy the use of weights, cardio machines, locker rooms, classes and more.

• On-site cafeteria, serving hot breakfast and lunch, at the Brooklyn, OH headquarters.
• Discounts at many places in and around town, just for being a Medical Mutual team member.
• The opportunity to earn cash rewards for shopping with our customers.
• Business casual attire, including jeans.

Excellent Benefits and Compensation :

• Employee bonus program.
• 401(k) with company match up to 4% and an additional company contribution.
• Health Savings Account with a company matching contribution.
• Excellent medical, dental, vision, life and disability insurance insurance is what we do best, and we make affordable coverage for our team a priority.
• Access to an Employee Assistance Program, which includes professional counseling, personal and professional coaching, self-help resources and assistance with work / life benefits.
• Company holidays and up to 16 PTO days during the first year of employment with options to carry over unused PTO time.
• After 120 days of service, parental leave for eligible employees who become parents through maternity, paternity or adoption.

An Investment in You :

• Career development programs and classes.
• Mentoring and coaching to help you advance in your career.
• Tuition reimbursement up to $5,250 per year, the IRS maximum.
• Diverse, inclusive and welcoming culture with Business Resource Groups.

About Medical Mutual :

Medical Mutual's status as a mutual company means we are owned by our policyholders, not stockholders, so we don't answer to Wall Street analysts or pay dividends to investors.

Instead, we focus on developing products and services that allow us to better serve our customers and the communities around us.

There's a good chance you already know many of our Medical Mutual customers. As the official insurer of everything you love, we are trusted by businesses and nonprofit organizations throughout Ohio to provide high-quality health, life, disability, dental, vision and indemnity plans.

We offer fully insured and self-funded group coverage, including stop loss, as well as Medicare Advantage, Medicare Supplement and individual plans.

Our plans provide peace of mind to more than 1.2 million Ohioans.

We're not just one of the largest health insurance companies based in Ohio, we're also the longest running. Founded in 1934, we're proud of our rich history with the communities where we live and work.

At Medical Mutual and its family of companies we celebrate differences and are mutually invested in our employees and our community.

We are proud to be an Equal Employment Opportunity and Affirmative Action Employer. Qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender perception or identity, national origin, age, marital status, veteran status, or disability status.

We maintain a drug-free workplace and perform pre-employment substance abuse and nicotine testing.