This role will ensure network adequacy and compliance by interacting with pharmacy providers regarding credentialing, contract language terms and conditions, claims or compensation issues, and provider education. In this role, the network specialist will optimize interactions with providers, and internal business partners to establish and maintain productive relationships to ensure provider retention, compliance with state and federal regulatory requirements and client needs
Coordinate, review and finalize the credentialing and re-credentialing process for approximately 68,000 network providers.
Update and maintain the credentialing database to house provider data accessible for CMS and client audits.
Solicit, review and finalize network contracting packets to ensure network adequacy, client retention and member access.
Assist in managing the network platforms/adjudication system including input of applicable information to ensure proper claims processing and payment.
Act as the first point of contact for the Call Center regarding pharmacy contractual issues and escalations.
Communicate pertinent information such as notices, provider education and payer sheets to pharmacies to prevent claims processing issues impacting members.
Ensure proper set up of payment information for 68,000 network providers to include bank account information (EFT) and the set up for delivery of HIPAA compliant electronic remittances ( ERA).
Research and respond to providers and internal team members for payment or member grievances.
Provide other assistance as needed to the Provider Relations team and other departments.
Other Job Requirements
Responsibilities
5+ years of experience in PBM, credentialing, claims, insurance administration or a health care setting.Analysis and problem solving skills required.Ability to interface with multi-disciplinary high level professionals.Ability to identify barriers and elevate issues.Strong interpersonal and communication skills, both written and verbal.Ability to establish strong relationships and influence work performance of others.Intermediate MS Excel and strong skills in other MS Office products.
General Job Information
Title
Sr Network Management Specialist, MRx
Grade
22
Work Experience - Required
Healthcare, PBM (Pharmacy Benefit Management)
Work Experience - Preferred
Education - Required
A Combination of Education and Work Experience May Be Considered., Bachelors
Education - Preferred
License and Certifications - Required
License and Certifications - Preferred
Magellan Health, Inc. is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled.Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their position; and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.
Magellan is the employer of choice for hard working people interested in making a difference in the health care industry and in the communities where we work and live. Our strong culture of caring is the common thread in both our business strategy and our work environment. We value professional growth and development, total health and wellness, rewards and recognition as well as employee unity. Magellan is a place where you can thrive.
Magellan is committed to providing equal employment opportunities to employees and applicants for employment without regard to race, color, creed, religion, sex, gender identity and expression, sexual orientation, marital status, age, national origin, ancestry, citizenship, physical or mental disability, disabled veteran or veteran of the Vietnam Era status, or any other factors protected by law.
Magellan is committed to meeting applicable Federal labor and employment law posting requirements by providing necessary posters in a format which is easily accessible and conspicuous to all applicants. Copies of applicable posters are accessible by clicking here (https://www.magellanhealth.com/media/760295/mg-federal-contractors-applicant-english.pdf) .
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Please know that Magellan Health does not interview any candidate through email, nor do we issue checks to candidates to set up home offices. All of our available positions are posted on legitimate job boards and our recruitment team directly contacts candidates should there be a fit.
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