Provider Network Specialist

US Family Health Plan- A TRICARE Prime option; New York (NY); Hybrid; USD 70,000 - 75,000; Full time

Benefits offered by this job

Medical coverage

Vision coverage

Dental benefits

Life and disability insurance

401(k) with employer match

Commuter benefits

Tuition reimbursement

Vacation time, holidays, personal days

Employee discounts

Employee Assistance Program

Job summary

US Family Health Plan- A TRICARE Prime option is seeking a Provider Network Specialist to build and maintain strong relationships with healthcare providers and ensure provider satisfaction.

You will serve as the primary contact between providers and internal departments, supporting network performance and ensuring compliance with contractual and regulatory requirements, while educating providers on policies and TRICARE guidelines.

Qualifications

• 5-8 years’ experience in health insurance, provider network or provider contracting.
• Access to personal vehicle and valid driver’s license.
• Able to lift 20 pounds.
• High school diploma required; associate’s degree preferred.

Responsibilities

• Educate providers on Plan policies, procedures, billing guidelines and TRICARE requirements.
• Support onboarding and orientation of newly contracted providers and participate in ongoing training.
• Monitor network adequacy and respond to gaps, access and availability.
• Collaborate with internal departments to resolve provider issues and ensure beneficiary needs.
• Assist providers with claims resolution, credentialing inquiries, contract interpretation and system navigation.
• Track provider inquiries, issues and trends; report to management.
• Communicate with prospective and contracted providers; conduct site visits (virtual or in-person).
• Maintain accurate documentation of provider interactions and contacts.
• Partner with marketing/sales teams for market growth and brand recognition.
• Analyze provider performance metrics and support quality initiatives with the Quality Department.

Skills

Interpersonal skills

Organizational skills

Presentation skills

Verbal and written communication

Data entry

Multitasking

Medical terminology

Salesforce

Microsoft Office

Access

Education

High School Diploma Required

Associate’s Degree Preferred

Tools

Microsoft Office

Access

Salesforce

Job description

Job Summary

The Provider Network Specialist is responsible for developing and maintaining positive working relationships with healthcare providers, ensuring provider satisfaction, resolving issues, and supporting network performance.

Job Summary

The Provider Network Specialist is responsible for developing and maintaining positive working relationships with healthcare providers, ensuring provider satisfaction, resolving issues, and supporting network performance. This role acts as the key point of contact between providers and internal departments to ensure efficient communication and compliance with contractual and regulatory requirements.

Responsibilities

• Educate providers on Plan policies, procedures, billing guidelines and TRICARE requirements.
• Support onboarding and orientation of newly contracted providers as well as participate in ongoing training to ensure understanding and adherence of Plan policies, programs, TRICARE requirements and contractual obligations.
• Monitor network adequacy and respond appropriately; including gaps/access and availability.
• Collaborate with internal departments to resolve provider issues and ensure beneficiary needs.
• Assist providers with claim resolution, credentialing inquiries, contract interpretation and system navigation.
• Address inquiries and resolve issues; track, trend and report provider inquiries/issues to management.
• Actively communicate with prospective and contracted providers.
• Conduct provider site visits (virtual or in-person) to maintain strong relationships and ensure compliance.
• Maintain an accurate list of contacts, including but not limited to, Managed Care, Credentialing, Claims, Contracting, Quality and Population Health executives and/or representatives manages territory.
• Maintain accurate documentation of provider interactions; track inquiries and monitor towards resolution.
• Partner with marketing/sales teams and participate in outreach activities/events, targeting market growth, penetration and building brand recognition.
• Analyze provider performance metrics (quality, utilization, and data analytics).
• Collaborate with Quality Department (HEDIS) to help reinforce Plan quality standards and increase positive patient outcomes.
• Identify trends in provider concerns and recommend process improvements.
• Additional interdepartmental duties as assigned.

Years Of Experience

• Associate’s degree (i.e., business management, healthcare management) OR equivalent experience.
• Required experience: 5-8 years’ experience in health insurance, provider network or provider contracting.
• Access to personal vehicle.
• Valid driver’s license.
• Able to lift 20 pounds.

Technical Skills/Competencies

• Strong interpersonal and relationship building skills
• Strong organizational skills and detail oriented
• Excellent presentation skills
• Excellent verbal and written communication skills
• Excellent data entry skills
• Ability to manage multiple priorities and meet stringent deadlines
• Medical and managed care terminology
• Proficiency in Microsoft Office, Access and Salesforce

EDUCATION

• High School Diploma Required / Associate’s Degree Preferred

SALARY RANGE: $70,000.00 - $75,000.00

Benefits Statement

SVCMC, Inc. provides a robust benefits package that includes medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services. Employees also receive vision coverage through UnitedHealthcare Vision and dental benefits through MetLife. Basic life and disability insurance are automatically provided at no cost. All employees are eligible for commuter benefits, tuition reimbursements, and a 401(k)-retirement plan with an immediate employer match that is fully vested from day one. SVCMC also offers a generous time off package, which includes vacation, 10 paid holidays, and 3 personal days. Additionally, employees have access to a comprehensive Employee Assistance Program and exclusive discounts through Working Advantage.

SVCMC IS AN EQUAL OPPORTUNITY EMPLOYER - ALL QUALIFIED APPLICANTS WILL RECIEVE CONSIDERATION FOR EMPLOYEMENT WITHOUT REGARD TO PROTECTED VETERAN STATUS, DISABILITY, OR OTHER CHARACTERISTICS PROTECTED BY LAW.

Monday - Friday 8:30 am - 4:30 pm

Mondays & Fridays Remote

Tuesday through Thursday In Office