As one of the fastest growing Independent Physician Associations in Southern California, Regal Medical Group, Lakeside Community Healthcare & Affiliated Doctors of Orange County, offers a fast-paced, exciting, welcoming and supportive work environment. Opportunities abound, and enterprising, capable, focused people prosper with us. We promote teamwork, nurture learning, and encourage advancement for all of our employees. We want to see you excel, because we believe that your success is our success.
We currently have an opening for a Provider Relations Network Specialist in the San Diego area.
The network specialist is responsible for providing administrative support to the Executive assigned and is also responsible for working as the internal liaison in maintaining, processing and reviewing department databases and reporting on a daily basis to assist the Network Management Department in meeting the overall network growth and development goals.
Essential Duties and Responsibilities include the following:
Provides coordination of administrative functions for the Executive and associated department staff that is responsive to customer needs and supports fulfillment of Heritage Provider Network and Regal Medical Group mission and values.
Creates forms and documentation, including memos, notices and drafts of Policies and Procedures as requested.
Handles telephone calls as needed for executive assigned.
Facilitates the scheduling of meetings for the executive or the department with providers.
Assist in Network growth and development to include preparation of contract packets for recruitment projects.
Responsible to work with Network Managers and providers to obtain proper signatures and documentation to effectively process newly recruited or existing providers.
Maintaining and updating the appropriate databases and department tools with statuses.
Coordinate receipt and processing of all provider contracts, credentialing, and correspondence.
Responsible for timely and accurate completion of PACF's related to incoming documentation received from providers regarding changes to their demographic information in the credentialing and provider network databases.
Responsible for initial review of all credentialing applications prior to submittal to RMG Contracts for completion and accuracy.
Working collaboratively with Network Managers during the contracting process to ensure department goals and requirements are being met.
Responsible for the initial submittal of provider profiles to the Health Plans and follow-up (as requested) to ensure PCP's are active in databases.
Limited contract negotiations under the direction of the Director, Network Management and/or Vice President of Regional Operations.
Daily interaction with regional providers.
Ensure contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as required by contracting HMOs.
Internal network liaison for Database, Claims, Customer Service, Medical Management, and Provider Relation Departments.
Perform on-site visits (as required) to physicians, physician groups, hospitals and ancillary providers.
Oversight of database maintenance and accuracy through use of audits.
Ensure accurate and timely data reporting requirements are being met .
Know and follow the Employee Handbook policies and procedures.
Maintain patient confidentiality so that HIPPAA compliance is observed at all times.
Other duties may be assigned as needed.
Distribution of work:
Daily production will vary from day to day. All assigned work must be completed by the end of business day in order to maintain turnaround time compliance.
Special Projects-Assist with any special projects.
Education and/or Experience:
1.Minimum of 2 years relevant work experience in Network Management in a managed care setting, health plan or large medical group administration.
2.Knowledge of contracting principles/tools.
3.Excellent verbal and written communication skills.
4.Proficient in MS Office programs (i.e., Word, Excel, Outlook, Access and Power Point)
5.Must be able to travel within the San Diego service area and have valid driver's license and insurance.
6.This position requires occasional travel out to the San Bernardino office for meetings .
We offer a full benefits package which includes employer paid medical, pharmacy and dental benefits. We offer a generous PTO package, 401k Retirement Savings, Life Insurance, Flexible Spending Account (FSA), Tuition Reimbursement & Licensed Renewal Fees for our clinical staff.