Provider Network Specialist – Disputes
Partners Health Management
full-time
Posted on:
Location Type: Remote
Location: North Carolina • United States
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About the role
- Manages provider disputes, sanctions, and terminations and monitors the process for each of those ensuring a high-quality network to serve Partners members.
- Oversees the follow-up and management of the provider dispute resolution process including notification letters of receipt of dispute, tracks timelines, maintains dispute log, conducts complete and thorough investigation of dispute, composes notification letter to provider related to that decision.
- Visits provider agencies to facilitate communication & collaboration as needed.
- Obtains and maintains information regarding provider sanctions, terminations and disputes.
- Completes routine and ongoing contract compliance monitoring to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations.
- Interprets audit results, identifies trends/patterns that impact service/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree of quality through the Network Management Committee.
- Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the Member Engagement Department, the Program Integrity Department, the Quality of Care Committee, Network Management Committee or as indicated by another agency or departmental identified need.
- Serves as a subject matter expert and as a resource to other departments within the LME/MCO on provider issues specifically related to provider terminations, sanctions and dispute information when appropriate.
- Manages notification and tracking of provider contract terminations.
- Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed.
- Monitors all NMC issued sanctions for all providers.
- Maintains a log of all Medicaid and IPRS procurement contract terminations.
- Participates in oversight and monitoring reviews of the MCO including but not limited to NCQA and EQR reviews as appropriate.
- Interpreting and assisting in developing and maintaining policies and procedures.
Requirements
- Bachelor’s Degree in mental health, public health, social work, psychology, education, sociology, business or public administration
- Two (2) years of experience in a community, business, or governmental program in health-related fields, social work or education including experience in network operations, provider relations and management experience.
- Exceptional interpersonal and communication skills
- Strong problem solving, negotiation, arbitration, and conflict resolution skills
- Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint)
Benefits
- Competitive Compensation & Benefits Package!
- Annual incentive bonus plan
- Medical, dental, and vision insurance with low deductible/low cost health plan
- Generous vacation and sick time accrual
- 12 paid holidays
- State Retirement (pension plan)
- 401(k) Plan with employer match
- Company paid life and disability insurance
- Wellness Programs
- Public Service Loan Forgiveness Qualifying Employer
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
provider dispute resolutioncontract compliance monitoringaudit interpretationpolicy developmentinvestigationdata trackingnetwork operationsprovider relationsconflict resolutionnegotiation
Soft Skills
interpersonal skillscommunication skillsproblem solvingarbitrationcollaborationtechnical supportmonitoringteamworkleadershipadaptability