Provider Network Job Description
Provider network
provides system set up instruction to Sutter Physician Services (SPS) on how to configure and update data within the claims processing system (Tapestry).
Provider Network Duties & Responsibilities
To write an effective provider network job description, begin by listing detailed duties, responsibilities and expectations. We have included provider network job description templates that you can modify and use.
Sample responsibilities for this position include:
Evaluate and monitor providers’ performance and the financial performance of contracts and coordinate partnership meetings with key Physicians and hospital providers
Oversee Provider Relations Representatives assigned to territories in NYS and NJ
Manage the Home Care Fund plan including roster distribution
Assist with implementation of cost containment programs
Generate reports to track staff performance
Assess training needs and develop plans to ensure staff are trained on policies and procedures, and new programs
Recruit and develop provider networks to meet on-going membership needs including but not limited to network strategy, provider identification, relationship development, contract negotiation and execution
Develop and maintain a Provider Manual and Provider Services Policies (appropriate to the geographic operating area) and provider collateral materials for recruitment and training
Orient and train providers regarding the company's operations
Meet with hospital and physician group representatives on regular basis to identify contractual and partnership opportunities
Provider Network Qualifications
Qualifications for a job description may include education, certification, and experience.
Licensing or Certifications for Provider Network
List any licenses or certifications required by the position: PMP, CCIE, CCNP, BLS, CEH, II, IAT, CCSE, CISSP, AHIMA
Education for Provider Network
Typically a job would require a certain level of education.
Employers hiring for the provider network job most commonly would prefer for their future employee to have a relevant degree such as Bachelor's and Master's Degree in Education, Business, Healthcare, Health Care, Management, Health, Business/Administration, Health Information Management, Administration, Finance
Skills for Provider Network
Desired skills for provider network include:
Claims processing systems and guidelines
Medicare Resource Based Relative Value System
Ambulatory Surgery Center Groupers
DRGs
Resource Based Relative Value System
Medicare reimbursement methodologies
Contracts
Products
Applications
Claims processing systems
Desired experience for provider network includes:
Proficiency in all Microsoft Office Programs, Word, PowerPoint, Excel, Access, etc
Proficiency in all Microsoft Office Programs, Word, PowerPoint, Excel, Access
Desire to progress into a provider contracting role
Consulting experience/capability
Bachelor’s Degree in Business, Finance, Operations/related fields or equivalent combination of education and experience
Prior exposure to regulatory requirements and timelines (CMS experience preferred)
Provider Network Examples
1
Provider Network Job Description
Job Description Example
Our company is growing rapidly and is looking for a provider network. Thank you in advance for taking a look at the list of responsibilities and qualifications. We look forward to reviewing your resume.
Responsibilities for provider network
- Work collaboratively with the Directors of Client Services and Marketing & Sales to achieve program initiatives
- Work with internal staff to resolve provider issues around billing, denials, payment, authorization, interaction and other provider issues
- Develop and distribute communication materials, including provider service manuals, provider management reports, network directories and other materials as necessary
- Assesses training needs of Provider personnel, (physician, PPG’s, Hospitals, Ancillary)
- Develop, maintain and enhance the Plan's relationship with contracted providers (Hospitals, ancillary and/or practitioner)
- Develops goals, work plans and schedules for provider staff and ensures that they are executed
- Establishes and maintains superior provider relations through the development of effective and efficient services programs, maintaining strong provider relationships
- Monitors compliance and financial performance for all providers
- Liaise with hospitals/nursing homes/wellness partners on a daily/periodical basis
- Be an interface between the hospitals and CignaTTK claims/customer service team
Qualifications for provider network
- A minimum of 3 years’ experience with CMS funding and MLR related cost structures
- Candidate will need to help build the team through various means of staff augmentation to meet the goals
- Candidate will be a key stakeholder to define the vision and strategies for Data Center network
- Minimum of 7 years of progressively responsible technical management and thought leadership
- Bachelor's degree (B.A.) from four-year college or university or equivalent technical experience in information systems, computer science, engineering, or related field strongly desired
- Relevant network or security certifications and vendor specific training (such as CISSP, CCIE, JNCIE)
2
Provider Network Job Description
Job Description Example
Our innovative and growing company is looking to fill the role of provider network. If you are looking for an exciting place to work, please take a look at the list of qualifications below.
Responsibilities for provider network
- Be actively involved in organizing wellness & health camps/services in corporates
- Ensuring tie ups with in stipulated time frame
- Provider contracting and tariff negotiation on the best available rates
- Responsible for overall activities related with empanelment of hospitals/nursing homes/wellness vendors
- Updating records and network presence intermittently
- Maintaining and publishing dashboard for empanelment, savings and de empanelment
- Periodic audit of Network providers/TPA’s with random onsite visits
- Ensure adequate tracking mechanism is in place to quantify the cost savings through negotiated tariffs
- Works in co-ordination with the providers to ensure superior health care delivery at hospitals
- Plan strategically and act tactically to implement oncology initiatives using project management disciplines for efficient and high quality results
Qualifications for provider network
- Background in large-scale project management, budget planning, ITIL, ISO 9001 planning
- Minimum three years’ experience in provider network development preferred
- Develops budget targets for HTPN practices
- Coordinates building and renovation projects
- Educated to University degree standard or equivalent
- Guide the research needs of prioritized program elements
3
Provider Network Job Description
Job Description Example
Our company is searching for experienced candidates for the position of provider network. Please review the list of responsibilities and qualifications. While this is our ideal list, we will consider candidates that do not necessarily have all of the qualifications, but have sufficient experience and talent.
Responsibilities for provider network
- Responsible for the documentation and/or modification of business requirements, workflow diagrams and instructions needed to support the delivery of program initiatives
- Collaborate with internal subject matter experts and vendor ops/tech teams to research ad hoc systematic and technology-related program issues
- Organize & lead multidisciplinary teams to execute and achieve program deliverables
- Analyze data prior to contracting meetings
- Conducts analyses and makes recommendations on next steps
- Directs all activities to ensure that Provider Network Management remains compliant with NCQA, Medicare, HMO, and Exchange regulations
- Utilize critical thinking skills and sound judgment in decision making
- Incumbent must maintain minimum number of files reviewed on a daily basis industry standard refute overturn rate
- Development and management of payment policies, processes, and programs
- Oversight for provider data management
Qualifications for provider network
- Visual Basic, SQL experience
- Oversee all provider outreach activities to ensure that education for providers and resolution of issues are delivered in an accurate, timely, professional and courteous manner
- Plan, prepare, and present programs, materials and publications to participating providers
- Primary point of contact and resource to resolve issues raised by, or impacting, the Plan's providers and related support staff
- Interact with hospitals, physicians and other provider contractors to examine specific policies, procedures, complaints in a manner which yields a positive resolution that meets Plan standards, while maintaining provider satisfaction
- Organize and prepare materials and represent Plan at meetings
4
Provider Network Job Description
Job Description Example
Our innovative and growing company is hiring for a provider network. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for provider network
- Responsibility for provider credentialing
- Provider contract loads, process improvement and data quality programs
- Contract process automation, capability and reporting
- Business lead for the implementation of the new provider contract management system
- Complex provider issue management, root cause assessment and resolution
- Provider communication, education and training
- Business owner for provider directory
- Gain, align and act on market intelligence from provider community
- Responsible for provider service and outcomes related to provider self- service strategies Provider engagement/satisfaction measures, improvement and reporting
- Overall business integration focus between internal/external provider constituents and stakeholders
Qualifications for provider network
- CAS, MTV, PIMS, EMPI, PAAG, PSP knowledge
- Mentor experience
- Requires excellent communication skills (written and verbal) and interpersonal skills
- Demonstrated customer service skills, time management and organizational skills
- Ability to communicate effectively to groups and individuals
- Identify, anticipate and solve complex problems, and intervene on behalf of the Plan or a provider to resolve conflicts in a positive manner and to reach an acceptable result
5
Provider Network Job Description
Job Description Example
Our company is growing rapidly and is looking to fill the role of provider network. We appreciate you taking the time to review the list of qualifications and to apply for the position. If you don’t fill all of the qualifications, you may still be considered depending on your level of experience.
Responsibilities for provider network
- Resolves difficult complex contract issues to ensure that provider contracts are in compliance with state, federal, national accrediting agencies and Plan contracting guidelines
- Responsible for the accuracy and timely management of all provider contracts
- Develop and execute Provider Connectivity strategy
- Leadership for the design and build of e-capabilities
- Maximize market adoption for all capabilities
- Serves as resource for lower-leveled contractors/consultants
- May collaborate with leadership team in representing organization at conferences
- Responsible for close collaboration with the Health Plan Medical Director to optimize network performance
- Partners with Product and LOB teams to ensure network design supports product objectives
- Design and execute on performance management processes to demonstrate network performance
Qualifications for provider network
- Ability to work independently and assume responsibility for the completion of special projects in a timely manner
- Provider Relations experience is preferred
- Health Insurance or managed care experience is preferred
- Travel to provider offices, hospitals, health fairs may be required
- Solid understanding of network structures and provider revenue models
- Comprehensive understanding of hospital and physician financial issues and how to leverage technology to achieve quality and cost improvements for both payers and providers