Network Service Consultant

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⚔️ Virginia, West Virginia – Remote

⚔️ Virginia – Remote ⛰️ West Virginia – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

💼 Consultant

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WVU Medicine

WebsiteLinkedInAll Job Openings

10,000+ employees

🏥 Healthcare

⚕️ Healthcare Insurance

Healthcare • Healthcare Insurance

WVU Medicine is a comprehensive health system affiliated with West Virginia University, providing medical services through a network of hospitals across West Virginia. The system includes notable facilities such as J. W. Ruby Memorial Hospital, WVU Medicine Children's, and various other regional medical centers. WVU Medicine offers a wide range of healthcare services, including specialized and advanced medical treatments such as robotic heart surgery. It's also involved in medical education, research, and community health initiatives, emphasizing a mission of delivering high-quality care to the communities it serves.

📋 Description

• Develop and maintain collaborative relationships with physicians, hospitals, ancillary providers, and vendors • Shape the provider network landscape through objective data and education across stakeholders, markets, and product lines • Educate providers on credentialing, contracting, authorizations, referrals, claims, 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 dealing 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

🎯 Requirements

• Bachelor’s Degree in business or a healthcare-related field • Basic understanding of contracts, Value Based Reimbursement (VBR), 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 • Willingness to travel to offsite meetings when required

🏖️ Benefits

• Full-time, 40 scheduled weekly hours • Remote work location • Some travel may be required to offsite meetings