Provider Network Specialist

Job Summary

This role serves as the primary liaison between the US Family Health Plan and its network of healthcare providers. The specialist is responsible for cultivating and maintaining strong relationships within the provider community, educating them on Plan standards and TRICARE requirements. Key duties include managing the new provider orientation program and delivering ongoing training to ensure a thorough understanding of Plan policies, programs, TRICARE regulations, and contractual obligations. The position involves monitoring network adequacy, collaborating with marketing and family practice center staff to meet beneficiary needs, and acting as the main point of contact for provider inquiries and issue resolution, including tracking, trending, and reporting these to management.

Responsibilities

• Engage proactively with prospective and contracted providers based on business needs.
• Guide new providers through the application, credentialing, and contracting stages.
• Conduct in-person site visits for prospective providers as per Plan requirements.
• Deliver new provider orientation sessions and continuous training as needed.
• Cultivate and nurture positive relationships within the provider network.
• Develop and enhance connections with providers, their office staff, and key stakeholders.
• Maintain an up-to-date directory of contacts within Managed Care, Credentialing, Claims, Contracting, Quality, and Population Health departments.
• Manage a designated territory, including strategic network partnerships and collaboration with the Plan's family health centers and marketing teams.
• Act as the central contact for general inquiries regarding USFHP products, provider manual details, provider directory accuracy, data integrity, and adherence to Plan policies and procedures, including claims management.
• Organize and conduct site visits to high-volume provider offices/facilities according to the department's project plan.
• Investigate, resolve, and respond to a wide range of provider inquiries, such as participation and credentialing requirements, contract terms, fee schedules, claims, reimbursement, utilization, access standards, member eligibility, and consult report needs.
• Document and monitor all received inquiries until resolution, adhering to Plan policies and TRICARE regulations.
• Facilitate cross-departmental collaboration to address and resolve complex provider issues, tracking trends.
• Collaborate with marketing and sales teams on outreach initiatives to drive market growth, penetration, and brand awareness.
• Generate analytical reports on network status, identifying gaps in access and availability.
• Oversee contract performance and network adequacy through site visits, claims data, and analytics.
• Ensure compliance with quality and regulatory guidelines, participating in HEDIS activities.
• Work with the Quality Department to reinforce Plan quality standards and improve patient outcomes.
• Perform additional inter/intradepartmental duties as assigned.

Requirements

• Possess 3-5 years of experience in health insurance, provider relations, provider contracting, network development, or credentialing.
• Alternatively, a minimum of 5-8 years of relevant work experience combined with an Associate’s degree or progress towards a Bachelor’s degree is acceptable.
• Must be able to lift up to 20 pounds.
• Proficiency in Microsoft Office Suite (Word, Excel, PowerPoint), with experience in Access and Salesforce being advantageous.
• Demonstrate strong organizational skills and meticulous attention to detail.
• Exhibit excellent presentation capabilities.
• Possess strong data entry skills.
• Ability to meet strict deadlines and adapt priorities to business demands.
• Excellent communication and analytical abilities.
• Familiarity with medical and managed care terminology.
• Hold a valid driver’s license and have access to a personal vehicle.

Perks

• Comprehensive medical coverage through UnitedHealthcare/Oxford with no deductible for in-network services.
• Vision coverage provided by UnitedHealthcare Vision.
• Dental benefits administered by MetLife.
• Complimentary basic life and disability insurance.
• Eligibility for commuter benefits.
• Tuition reimbursement program.
• 401(k) retirement plan with an immediate, fully vested employer match.
• Generous paid time off, including vacation days, 10 paid holidays, and 3 personal days.
• Access to a comprehensive Employee Assistance Program.
• Exclusive discounts through Working Advantage.

Eligibility

This position is open to all qualified applicants. Specific experience requirements include 3-5 years in health insurance, provider relations, provider contracting, provider network development, or provider credentialing. An alternative pathway includes 5-8 years of relevant work experience with an Associate’s degree or if currently pursuing a Bachelor’s degree. A valid driver's license and access to a personal vehicle are necessary.

Education Required

Associate’s Degree required; Bachelor’s Degree preferred.

Skills

• Provider Relations
• Network Development
• Contract Management
• Healthcare Compliance
• TRICARE Regulations
• Microsoft Office Suite
• Salesforce
• Data Analysis
• Communication
• Problem Solving
• Presentation Skills
• Organizational Skills