This position is responsible for the support of all activities related to developing and maintaining the physician, practitioner, group, and/or facility, MPPS and organization services delivery system in small to mid-size market defined by membership, number of providers in delivery system, number of business operating units and lines of business. Interacts with all areas of organization to coordinate network management and network administration responsibilities.
Assesses network needs, analyzes network composition, and using organization databases, application of regulatory requirements, accreditation entities and other resources, recruits individual, group and/or organizational providers to meet network adequacy standards and assure quality network.
Conducts and coordinates contracting and amendment initiatives.
Provides issue resolution and complex trouble shooting for providers.
Conducts provider education and provider relation activities, providing necessary written materials.
Conducts administrative provider site visits and coordinates report development and completion according to contractual requirements or ad hoc requests.
Coordinates Public Policy Research Center (PPRC) activities to assure maintenance of current credentialing status, and evaluation and appropriate actions of quality of care issues and complaints against providers.
Conducts and manages ongoing audits of provider compliance with Magellan policies and procedures as well as contractual obligations for multiple customers. Develops work plans to address audit requirements.
Works with management to draft, clarify and recommend changes to policies which impact network management.
Other Job Requirements
Responsibilities
Knowledge of National Committee for Quality Assurance (NCQA) requirements.Ability to work independently and prioritize activities.Intermediate knowledge of Microsoft Office Suite, specifically Excel.Strong presentations skills using PowerPoint.Minimum of 1 year experience in related position/field.
General Job Information
Title
Provider Network Management Specialist
Grade
20
Work Experience - Required
Network
Work Experience - Preferred
Education - Required
Education - Preferred
Bachelors
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.
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