Network Operations Specialist

Job Description

Job Description

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role.

Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

Work Culture :

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive.

This philosophy enables us to create the health plan of the future and do our best work Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace :

• Integrity
• Accountability
• Collaboration
• Trust
• Respect

Disclaimers :

• Flexible work schedule is based on job duties, department, organization, or business need.
• Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Network Operations Specialist will liaise with healthcare providers and clients on healthcare-related issues, related to the GCHP processes, policies and procedures, contracting, reimbursement and the provider’s role in participating with governmental programs, including helping resolve queries and helping train healthcare providers to ensure operational efficiency.

The Network Operations Specialist should be highly organized and have excellent communication skills.

Amount of Travel Required : 50%+

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily.

Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

• Initiating and maintaining effective channels of communication with GCHP network providers.
• Participating in the departmental processes to help manage GCHP network providers, including collaborating with department colleagues and leadership for preparation of presentations, reports and documents for internal and external meetings.
• Participating in the onboarding of new GCHP network providers to ensure full compliance with regulatory requirements.
• Assisting departmental operations with investigating contracting questions, including interpretation of contract language as it pertains to the roles and responsibilities of a GCHP network provider, coding and reimbursement methodology.
• Assisting departmental operations and colleagues with gathering, reviewing, and verifying, within the regulatory required timeframes, all pertinent information relating to GCHP network providers.
• Managing and maintaining GCHP network provider data and rosters to ensure additions and terminations of participating providers, address / demographic changes, name changes, TIN, NPI updates and provider practice information changes are timely and accurately submitted to all applicable operational systems.
• Establishing and maintaining relationships with GCHP network providers through office visits, telephone calls, prompt resolution of issues, and excellent customer service.
• Participating and helping departmental colleagues with mandatory and ad hoc training with GCHP network providers on policies, procedures, service lines, and available technology as well as tracking all provider engagement for regulatory reporting purposes.
• Answering questions from GCHP providers to help drive resolution.
• Gathering, reviewing, and submitting relevant documentation needed for to help resolve complex claims inquiries and / or claims processing.
• Maintain understanding of applicable federal, state, and local laws and regulations regarding healthcare with a focus on Medicaid and Medicare.
• Notifying departmental colleagues and / or leadership of potential issues, shortfalls, and trends in GCHP provider network to help initiate improvement opportunities.
• Assist departmental colleagues on training of contract inquiries and / or contract issues that impact GCHP network providers’ roles and responsibilities.
• Assist departmental colleagues and leadership with preparation of materials and presentations for regularly scheduled meetings.

MINIMUM QUALIFICATIONS

Education & Experience : Please identify the nature of education and experience such as : Associates, Bachelor’s and / or

Master’s degree (four-year college or technical school) and list any applicable specialty or field of study.

• High School Diploma and 5 years of direct experience
• Minimum 5+ years health care / managed care experience in the health care field

Equivalent In lieu of degree :

• Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position.
• 5 years of direct healthcare experience

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications :

• Preferred : Bachelor's Degree (four-year college)
• Preferred : 3+ years preferred of provider relations and / or provider network experience interacting directly with providers.

Understanding and experience with Governmental Programs (Medicare and Medicaid), direct experience with State of California MediCal is a plus.

Technology & Software Skills : Advanced computer skills included in the MS Office products, specifically Word, Excel, PowerPoint, Teams and Outlook

Certifications & Licenses : A valid and current Driver's License, Auto Insurance

Professional licensure : N / A

Competency Statements

• Management Skills - Ability to organize and direct oneself.
• Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.
• Customer Oriented - Ability to take care of customer needs while following company procedures.
• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.
• Interpersonal - Ability to get along well with a variety of personalities and individuals.
• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.
18 days ago