Senior Network Operations Specialist

The pay range above represents the minimum and maximum rate for this position in California. Factors that may be used to determine where newly hired employees will be placed in the pay range include the employee specific skills and qualifications, relevant years of experience and comparison to other employees already in this role. Most often, a newly hired employee will be placed below the midpoint of the range. Salary range will vary for remote positions outside of California.

Work Culture:

GCHP strives to create an inclusive, highly collaborative work culture where our people are empowered to grow and thrive. This philosophy enables us to create the health plan of the future and do our best work – Together.

GCHP promotes a flexible work environment. Employees may work from a home location or in the GCHP office for all or part of their regular workweek (see disclaimer).

GCHP’s focuses on 5 Core Values in the workplace:

• Integrity

• Accountability

• Collaboration

• Trust

• Respect

Disclaimers:

• Flexible work schedule is based on job duties, department, organization, or business need.

• Gold Coast Health Plan will not sponsor applicants for work visas.

POSITION SUMMARY

The Network Operations Sr. Specialist will liaise with healthcare providers and clients on healthcare-related issues, related to the GCHP processes, policies and procedures, contracting, reimbursement and the provider’s role in participating with governmental programs, including resolving queries and train healthcare providers to ensure operational efficiency. The Network Operations Sr. Specialist should be highly organized and have excellent communication skills.

Reasonable Accommodations Statement

To accomplish this job successfully, an individual must be able to perform, with or without reasonable accommodation, each essential function satisfactorily. Reasonable accommodations may be made to help enable qualified individuals with disabilities to perform the essential functions.

ESSENTIAL FUNCTIONS

Essential Functions Statements

• Initiating and maintaining effective channels of communication with GCHP network providers.

• Effectively managing GCHP network providers, including participating in and leading joint operations meetings to help support company strategies and goals.

• Managing and collaborating with Quality, Operational, Financial departments for reporting of GCHP network provider performance including analyzing data to determine trends, findings and recommendations.

• Managing and collaborating with applicable departments on Corrective Action Plans resulting from performance and audit findings.

• Training and investigating contracting questions, including interpretation of contract language as it pertains to the roles and responsibilities of a GCHP network provider, coding and reimbursement methodology.

• Gathering, reviewing, and verifying, within the regulatory required timeframes, all pertinent information relating to GCHP network providers to ensure timely and accurate data and information for applicable operational systems.

• Establishing and maintaining relationships with GCHP network providers through office visits, telephone calls, prompt resolution of issues, and excellent customer service.

• Conducting mandatory and ad hoc training with GCHP network providers on policies, procedures, service lines, and available technology as well as tracking all provider engagement for regulatory reporting purposes.

• Answering questions from GCHP providers to drive resolution.

• Gathering, reviewing, and submitting relevant documentation needed for resolving complex claims inquiries and/or claims processing.

• Maintaining a working knowledge of all applicable federal, state, and local laws and regulations regarding healthcare with a focus on Medicaid and Medicare.

• Identifying issues, shortfalls, and trends in GCHP provider network to help initiate improvement opportunities.

• Manage and train on contract inquiries and/or contract issues that impact GCHP network providers’ roles and responsibilities.

• Conduct regularly scheduled meetings with providers and resolve outstanding issues.

MINIMUM QUALIFICATIONS

Education & Experience:

• High School Diploma or minimum of 8 years direct experience.

• Bachelor's Degree (four-year college) preferred

• At least 8 years health care/managed care experience in the health care field and at least minimum of 3 years of provider relations and/or provider network experience interacting directly with providers.

• Understanding and experience with Governmental Programs (Medicare and Medicaid), direct experience with State of California MediCal is a plus.

• Travel to multiple sites and different locations. Flexibility to work beyond normal business hours as needed.

Equivalent In lieu of degree:

• Will accept experience in any combination of academic education, professional training, or work experience, which demonstrates the ability to perform the duties of the position.

• Minimum 8 years’ direct experience.

• Four years of experience must be added in lieu of a bachelor’s degree when required.

KNOWLEDGE, SKILLS & ABILITIES

Preferred Qualifications:

• Five years preferred of provider relations and/or provider network experience interacting directly with providers.

• Technology & Software Skills: Advanced computer skills included in the MS Office products, specifically Word, Excel, PowerPoint, Teams and Outlook

Certifications & Licenses: A valid and current Driver's License, Auto Insurance

POSITION QUALIFICATIONS

Competency Statements

• Management Skills - Ability to organize and direct oneself and effectively supervise others.

• Initiative - Ability to make decisions or take actions to solve a problem or reach a goal.

• Customer Oriented - Ability to take care of customer needs while following company procedures.

• Diversity Oriented - Ability to work effectively with people regardless of their age, gender, race, ethnicity, religion, or job type.

• Interpersonal - Ability to get along well with a variety of personalities and individuals.

• Time Management - Ability to utilize the available time to organize and complete work within given deadlines.

Apply Here

PI253554059