The Provider Network Coordinator (PNC) is responsible for a wide range of activities to support, develop and maintain service relationships with all participants (physicians, hospitals and health systems, providers, and administrators) of the MSO provider network. Primary focus will be on timely completion of provider credentialing and re-credentialing activities, according to Health Plan, State, Federal and NCQA requirements, for over 1,000 network providers. The PNC is responsible managing and maintaining accurate data related to the provider and groups within the MSO provider network. This includes being the main point of contact for all provider information and collaborating with contracted health plans, internal teams and directly with providers to ensure accurate data collection and exchange.

The PNC ensures MSO network providers meet all credentialing and licensing requirements and is responsible for continuous monitoring of the entire provider network. The PNC plays a crucial role in building and sustaining a high-quality provider network by overseeing the data accuracy and credentialing of all healthcare professionals.|

ESSENTIAL JOB FUNCTIONS:

• Serve as point of contact between NEMS organization, MSO network providers, Health Plans and other community partners to support credentialing and provider data maintenance .
• Assist with the development of written communications for general NEMS MSO notifications, provider newsletter, MSO website, and maintaining provider on-line directory and tools/resources.
• Responsible for the initial credentialing and re-credentialing activities for new and recertified providers, including licensure verifications, follow up on completion of applications and/or missing/unclear data, according to Health Plan, State, Federal and NCQA requirements.
• Responsible for inputting and maintaining credentialing information for physicians and organizations, utilizing monitoring reports to tracking for physicians’ re-credential status, quality assurance information, verification of sanctions, and incident investigation status.
• Coordinate and facilitate the NEMS/MSO Credentialing/Privileging Committee meeting and follow up on action requests by the Committee.
• Be the point of contact for credentialing denials, provider complaints and/or appeals about credentialing.
• Carry out monthly monitoring activities to ensure NEMS MSO network providers are in compliance.
• Coordinate with contracted entities for Credentialing sub-delegation ongoing reports, rosters, and monitoring.
• Coordinate with contracted Health Plan(s) for annual delegation audits, and any other audits conducted by DHCS/DMHC/CMS as applicable. This includes preparing audit files and universes.
• Ensure all NEMS systems containing provider data are accurate and updated accordingly. Also communicate provider changes to other internal teams, as appropriate.
• Communicate with contracted Health Plans to report new, updated, or terminated physician and practice information as required per SB137.
• Submit accurate and complete provider rosters to contracted health plans based on contractual requirements. Update contracted health plan on provider/adds/terms and changes, as needed, between roster submissions.
• Research and understand complex issues raised by physician practices, and/or health plan partners, coordinate with other internal teams for follow up activities and resolution.
• Identify and research a variety of issues related to provider credentialing, compliance, and operational issues, utilizing various sources, including but not limited to current contracts, publications, websites, and provider notifications.
• Play an active role in supporting new team members and assist with trainings.
• Perform other duties as assigned.

QUALIFICATIONS:

• BA/BS degree; Associate Degree may be considered with relevant, equivalent work experience.
• 2-3 years work experience in healthcare setting in the areas of provider relations, claims, or utilization management is preferred.
• Knowledge of Medicare and/or Medi-Cal managed care program and/or other state-sponsored program is a plus.
• Prior managed care experience with knowledge of CMS/DHCS health policy is a plus.
• Superior ability to communicate (spoken and written) effectively with a variety of professionals, including physicians and other healthcare providers, business administrators and contracting managers, billing and revenue cycle agencies.
• Must be PC literate - Strong Excel, Word, Power point, and Outlook skills;
• Knowledge of community resources and culture is a plus.
• Detail-oriented and organized with the ability to interpret DHCS policy letters and make decisions.
• Good organization and problem-solving skills.
• Ability to self-manage and work with multiple departments within the organization and external clients.

LANGUAGE:

• Must be able to fluently speak, read and write English.
• Fluent in other languages are an asset.

STATUS:

This is an FLSA NON-exempt position.
This is not an OSHA high-risk position.