Network Specialist - Full Time, Days

The Network Management Specialist will support the Network Management Department and act as a liaison for internal staff and external customers to include providers, provider office staff, and other vendors while offering resolution to questions, concerns, issues, and grievances by way of education and training on Prospect Medical Policies and Procedures and Provider Manual. Individual will act as a resource for Network Management and MSO teams. Also responsible for escalated provider claims project research, premier provider PDR exceptions and assigned departmental special projects. May provide operations and procedures training and services to Network Management staff and other departments. With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS. Responsible for rolling out effective functional workflows applicable to Network Management and e-initiatives, including Ascender, Cerecons and Office Ally. Act as the lead liaison for promoting and conducting telephonic or in-house trainings on Prospect Medical electronic systems and online tools [Cerecons/Provider Tools, Office Ally and IDX], Performance Programs [Ascender, HCC, P4P and wellness clinics]. Training to be provided to internal staff and external customers. Handle incoming and outgoing e-mail and fax inquiries, answer internal and external calls and conduct outgoing telephone calls to provider offices, internal staff and external vendors to provide assistance or resolution. Education and resolution to include claims and capitation/fee for service payment inquires and PDR projects. Document all telephone calls, correspondence and e-mails pertaining to Network Management Provider Relations from Providers and internal staff inquiries in our IDX system and provide timely and thorough responses to all requests received as per Network Management Policies & Procedures. Comply with production report requirements as stated in Network Management Provider Relations Department Policies and Procedures. Perform business development and event coordination functions on and off-site to support Network Management team with membership growth activities and provider engagement. May perform additional duties and assist with special projects as assigned by V.P. of Network Management, Network Management Administrative Support Supervisor, Network Managers or other management staff as needed. Minimum Education: High school diploma or equivalent. Minimum Experience: Minimum five (5) years of IPA/HMO setting or equivalent experience in managed care including four (4) years in Provider Relations, three (3) years of claims/authorizations experience. Internal candidates must be cross-trained in and have a functional understanding in areas such as Medical Management, Referrals, Claims, Customer Service, Contract Interpretation and Credentialing. Req. Certification/Licensure: Must be proficient in Microsoft Office navigation, Access, Excel, and Word. Must be proficient using IDX systems. Must be proficient using Cerecons. Working Knowledge of Ascender Software and of Office Ally.

Created: 2024-11-10