Provider Services Specialist

* Provider Credentialing

* Complete the credentialing and recredentialing of all providers within the network.

* Ensure compliance with CMS regulations related to Medicare Advantage plan credentialing and recredentialing.

* Maintain accurate provider records and ensure timely updates in internal systems and external reporting.

* Work closely with internal departments (claims, utilization management, business development, network development, compliance, and finance) to ensure seamless coordination of provider credentialing and configuration.

* Address and resolve provider discrepancies, reconciliation issues, and other provider-related concerns.

* Provider Configuration

* Develop and implement strategies to improve provider database.

* Load and maintain provider demographic data within internal systems.

* Ensure timely turnaround time and quality standards of provider records.

* Ensure provider information is correctly configured to support claims processing, reporting and directory services.

* Participate in audit of provider records to ensure accuracy and quality.

* Provider Relations, Customer Service & Issue Resolution

* Ensure prompt and accurate responses to provider inquiries.

* Resolve escalated provider complaints, grievances, disputes and appeals in collaboration with other departments.

* Ensure call center or member support staff maintain high standards of professionalism and accuracy.

* Stay updated on regulatory changes and implement necessary updates to processes and policies.

* Participate in audits related to provider services.

* Maintain thorough documentation of provider credentialing and recredentialing activities and regulatory reporting as required.

* Collaboration & Process Improvement

* Work closely with internal departments, including Compliance, IT, and Finance to improve provider credentialing process.

* Identify and implement process improvements to enhance efficiency, accuracy, and provider experience.

* Assist in evaluating and implementing technology solutions for provider management.

* Participate in cross-training initiatives to support other provider functional areas to ensure continuity of operations and enhancing team versatility.