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Health Plan Provider Operations Specialist

Company: AltaMed
Location: Montebello
Posted on: September 16, 2022

Job Description:

*Job Summary: *The Health Plan Provider Operations Specialist is a key member of the Managed Care Department that aims to improve provider satisfaction and access to care. This position is responsible for the maintenance of provider data as well as paneling operations for the entire AltaMed network. The Health Plan Provider Operations Specialist will ensure providers are listed accurately in all health plans and across all applicable lines of business. This individual will monitor, assess, validate and implement standard paneling procedures to ensure health plan alignment to organizational goals. The position acts as a liaison between AltaMed and health plans to ensure changes are made to the Provider Network. In addition, the individual is responsible for ensuring quality of contracts initiated by the Contracting department in order to ensure compliance and that business rules are constantly met. Focusing on program and process compliance; this position will ensure regular, periodic evidence-based reviews and audits of internal processes, and will assist with identifying potential risk areas. Partners with multiple internal customers to measure progress against goals, identify trends, implement process improvements and make recommendations for required training or performance management.*Skills and Abilities: ** Effective communication skills (oral and written).* Strong interpersonal skills for frequent contact with internal/external customers.* Ability to work collaboratively with diverse individuals and situations, including strong problem solving and conflict resolution skills.* Ability to understand and respond appropriately, effectively, and sensitively to special population groups served.* Ability to plan, prioritize, and schedule multiple work assignments; high degree of organizational and time management skills.* Computer literacy: Word processing, spreadsheets, file management, and the use of healthcare software programs.* Excellent critical thinking, deductive reasoning, and decision making skills.* Self-motivated and action-oriented.* Thorough understanding of state, federal and other regulatory and accrediting bodies' standards and regulations for medical groups and health plans.* Knowledge of HIPAA Guidelines including the PHI privacy requirements.*Physical Requirements: ** Ability to sit, stand, stoop, reach, lift (up to 15 lbs), bend, etc., in carrying out regular and routine duties of position.* Reaching for and handling records, files, reports.* May require travel to sites/programs and specialized functions.*Environmental Conditions Critical to Performance: ** Work is in an office environment, climate controlled through central air conditioning.* Will be exposed to outside environmental conditions while traveling.*Education and Experience: ** Bachelor's degree in Business Administration, healthcare, organizational management or equivalent work experiencerequired.* Master's degree preferred.* A minimum of one year of member relations, claims, and/or provider relations experience preferred.* Knowledge of managed care and contracting principles preferred.* Bilingual English/Spanish preferred.* A minimum of one year of interaction with multiple health plans preferred.* A minimum of two years of experience using MS Access or SQL databases preferred.*Essential Job Functions of Job Description** Assists with data collection for provider network, including the tracking of contracts as they are routed for credentialing.* Responsible for submitting new provider contracts to Contracts Administration to ensure a hard file is created for record keeping/audit purposes.* Works with contracted Health Plans to ensure timely and accurate submission of provider profiles for paneling purposes.* Functions as support department to Provider Network on paneling operations.* Conducts research regarding any significant changes in membership and provides findings to leadership and subsequently reports findings to health plan liaisons.* Assists with administrative issues involving contracted primary care physicians, specialty care physicians, hospitals, and ancillary providers.* Create network rosters as well as update existing rosters and make available for internal customers.* Create and/or validate health plan rosters to ensure network accuracy and increase Provider Listing Accuracy (PLA).* Disseminates new and revised policies and procedures that relate to contracted providers.* Assist with the development of evidence-based, measurable internal audit tools and indicators.* Conduct internal administrative compliance audits and provide aggregate data reports.* Conduct follow-up with management to resolve issues of non-compliance identified through reporting activities and/or audits.* Develop and distribute reports to management regarding internal audits or reviews.* Assist with external audit activities, including audit preparation and corrective action planning activities.* Monitor corrective action plan implementation and initiate remedial measures to address implementation challenges.* Leads and participates in special projects; including but not limited to process development, compliance and training.* Develops and documents standard processes and workflows; collaborating with various stakeholders as needed.* Partners with stakeholders to analyze processes and make data driven recommendations for process improvement.* Submits requested reports to Supervisor as needed.* Performs other related duties as assigned.Job Type: Full-timePay: $25.00 - $30.00 per hourBenefits:* 401(k)* 401(k) matching* Dental insurance* Employee assistance program* Employee discount* Flexible schedule* Flexible spending account* Health insurance* Health savings account* Life insurance* Paid time off* Referral program* Retirement plan* Tuition reimbursement* Vision insuranceSchedule:* 8 hour shift* Monday to FridayCOVID-19 considerations:All employees and new hires must be fully vaccinated for COVID-19Ability to commute/relocate:* Montebello, CA 90640: Reliably commute or planning to relocate before starting work (Required)Work Location: One location

Keywords: AltaMed, Montebello , Health Plan Provider Operations Specialist, Healthcare , Montebello, California

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