Provider Network Operations Specialist

🔥 0 minutes ago

🌲 North Carolina – Remote

🌲 North Carolina – Remote

💵 $61.4k - $78.3k / year

⏰ Full Time

🟢 Junior

🌐 Network Operations

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Alliance Health

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 2012

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

Alliance Health is a regional health plan serving residents of several North Carolina counties by administering Medicaid and state-funded behavioral health and specialty services. It operates Tailored Plan coverage and Medicaid Direct options that integrate physical health, pharmacy, behavioral health, intellectual/developmental disability (I/DD), and traumatic brain injury (TBI) services, provides 24/7 behavioral health crisis support, member and provider portals, community trainings and outreach, and coordinates care through provider networks and governance committees.

📋 Description

• Support development and management of the Provider Network • Manage and maintain accurate Provider Scopes of Work (SOW) • Conduct clinical and financial SOW reviews according to established procedures • Meet with providers to review SOWs twice annually and as needed • Organize and lead interdepartmental SOW review meetings • Route SOWs into contracts for the following fiscal year • Ensure assigned provider contracts include applicable SOWs each contract year • Provide technical assistance, education, and customer service to network providers • Oversee the Provider Hub and monitor and share information • Research and troubleshoot provider issues • Provide targeted provider communications as assigned • Complete required reporting • Review funding and financial information and recommend future funding • Troubleshoot funding issues and adherence to best practices with providers • Ensure evidence-based and best-practice services are available to members • Maintain awareness of fidelity elements and adherence to standards • Support providers in developing and maintaining comprehensive, outcome-focused member services • Follow applicable NCQA standards for Provider Network Development functions • Collaborate with departments and external stakeholders • Represent Alliance in state calls, provider collaboratives, Provider Advisory Council meetings, and community crisis collaboratives • Assist with agendas and present at All Provider Meetings and Alliance Provider Advisory Council meetings • Facilitate assigned provider collaboratives • Establish and maintain relationships with public, private, and provider agencies • Monitor provider contracts and recommend contract development or termination • Review and approve invoices according to contractual terms • Discuss rate changes, funding, and other contract-impacting changes with management • Support special initiatives, including Letters of Support, HCBS, Waiver Requests, and Transition to Community Living • Monitor spending and revise funding caps across departments • Revise and maintain Scopes of Work

🎯 Requirements

• Bachelor’s degree in a Human Services field from an accredited college or university and three (3) years progressive post-degree experience in Mental Health, Substance Use, Intellectual/Developmental Disabilities or Physical Health; OR Master’s degree in Human Services from an accredited college or university with one (1) year post-graduate experience in those fields • Provider Networks experience preferred • Knowledge of disability areas including Mental Health, Substance Use and Developmental/Intellectual Disabilities • Knowledge of treatment, habilitation and support principles, concepts, and Best Practices • Knowledge of systems that impact Providers • Proficiency with Microsoft Office suite, including Excel • Database maintenance proficiency • Exceptional interpersonal skills • Highly effective communication skills • Problem solving, organizing, and conflict resolution skills • Public speaking and training skills • Mediation skills • Diplomacy and discretion to negotiate and resolve issues independently • Ability to make prompt independent decisions based on relevant facts • Ability to review and analyze data to evaluate program effectiveness, progress, problems, and system performance • Ability to work effectively with internal and external stakeholders • Ability to identify problems and initiate solutions • Ability to take initiative and utilize critical thinking • Must reside in North Carolina • Willingness to travel to an office for business or onsite team meetings as needed • Occasional local provider site visits may be required

🏖️ Benefits

• Full-time remote work • Occasional travel to offices for business or onsite team meetings as needed • Equal Opportunity Employer