Network Service Consultant

🕒 August 14

⚔️ Virginia, West Virginia – Remote

⚔️ Virginia – Remote ⛰️ West Virginia – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

👻 Ghost score 10%

What it means: how likely this posting is sitting open without active hiring.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Develop and maintain collaborative relationships with providers, including physicians, hospitals, ancillary providers, and vendors • Shape the provider network landscape through objective data and education across stakeholders and product lines • Educate providers on credentialing, contracting, authorizations, referrals, claims and encounters, grievances and appeals, health education, population health, care management, pharmacy management, electronic health records, health information exchange, data exchange, and regulatory updates • Conduct provider outreach through email, telephone, in-person meetings, and webinars • Assess provider efficiencies when interacting with the health plan • Conduct initial provider orientations and ongoing educational outreach • Conduct group training sessions • Assist with provider contract questions, research problems, and resolve escalated issues • Represent the health plan at healthcare association functions • Participate in regulatory reporting for provider networks • Monitor competitors and market regulations • Support strategic positioning to develop and maintain provider networks • Assist the Credentialing Department with difficult-to-obtain documents • Collaborate with Claims Operations, Medical Management, Credentialing, Contracting, Legal, Analytics, Compliance, Sales and Marketing, and Member and Provider Service teams • Report to the Manager Network Services as a member of the Provider Relations team

🎯 Requirements

• Bachelor’s Degree in business or a healthcare-related field • Basic understanding of contracts, Value Based Reimbursement, performance-based provider reimbursement programs, and Commercial, Medicare Advantage, Medicaid, and PEIA products • Understanding of regulatory reporting for provider networks, including the WV Department of Insurance, Department of Medicaid/Health Services, and CMS • Understanding of provider quality measurement systems such as Medicare STARS, HEDIS, and PCMH quality programs • Strategic thinking and attention to detail • Knowledge of federal and state laws, including CMS and BMS • Excellent written and oral communication • Demonstrated ability to build and retain relationships • Proficiency with Microsoft Office • Experience with Commercial, Medicare, and Medicaid products • Understanding of provider credentialing and data management processes • Working knowledge of claims and/or coding • Established provider relationships in West Virginia • Standard office-environment work conditions • Ability to travel to offsite meetings when required

🏖️ Benefits

• Full-time employment • 40 scheduled hours per week • Some travel may be required to offsite meetings • Reasonable accommodations may be made for individuals with disabilities