Job Details

Competitive Compensation & Benefits Package!

Position eligible for:

• Annual incentive bonus plan
• Medical, dental, and vision insurance with low deductible/low cost health plan
• Generous vacation and sick time accrual
• 12 paid holidays
• State Retirement (pension plan)
• 401(k) Plan with employer match
• Company paid life and disability insurance
• Wellness Programs
• Public Service Loan Forgiveness Qualifying Employer

Office Location: Flexible for any of our office locations; Remote option in NC

Projected Hiring Range: Depending on Experience

Closing Date: Open Until Filled

Primary Purpose of Position:

This position assists in the enrollment, maintenance, development and management of the Provider Network for members who have been identified as having mental health, substance use or intellectual development disability needs.

Role and Responsibilities:

A Provider Network Maintenance Specialist's primary duties may be one or more of the following:

• Responsible for reviewing, monitoring and ensuring compliance with facility licensure, national accreditation requirements, clinical coverage policies and other requirements related to the provision of behavioral health services;
• Responsible for receiving, reviewing, analyzing and entering time sensitive and confidential provider information;
• Responsible for ensuring that providers are properly enrolled in NC Tracks prior to enrolling them into the system.
• Demonstrates understanding of Tailored Plan and Medicaid Direct health plans
• Responsible for managing, tracking and filing information submitted to and information received from providers related to ongoing maintenance of provider enrollment and contracting;
• Responsible for managing, processing, tracking and filing requests from providers to join the network and requests from providers to make changes to their contracts;
• Responsible for regular follow-up of status of submitted requests to join the network and provider maintenance requests;
• Responsible for resolving issues and supporting providers regarding their requests to contract with or make changes to their contract with Partners;
• Responsible for monitoring and follow-up associated with the provider enrollment file and the provider network file;
• Participates in performance improvement activities;
• Receive and process requests for access to Partners Provider Portal
• Composes letters, memos and emails to internal and external contacts.
• Researches questions related to joining the Partners provider network and/or change requests and responds to internal and external contacts regarding concerns related to delays and inconsistencies in information;
• Demonstrates the ability to communicate professionally and clearly in both verbal and written form both internally and externally;
• Monitors and updates provider information as required;
• Accurately and clearly documents process steps, dates and work status.
• Verifies providers meet the requirements to provide services in the Network according to parameters determined for qualifications and needs of the Network;
• Interprets audit results, identifies trends/patterns that impact service/system quality, and then implements interventions aimed at addressing these trends/patterns with the outcome of services delivery to consumers at the highest degree of quality;
• Collaborates with Quality Management Department, Program Integrity Department, Provider Network Relations, Member Engagement, and Community Engagement to collect information related to quality of care for the purpose of enrollment of providers;
• Participates in complaint monitoring reviews/focused reviews/special investigative team reviews as requested by the Member Engagement Department, the Program Integrity Department, the Quality of Care Committee, Network Management Committee, or as indicated by another agency or departmental identified need;
• Serves as a resource to other departments within the LME/MCO on provider-related issues;
• Serves as a liaison with other departments within the LME/MCO and with various NC DHHS Departments, per rule requirements, to coordinate Specialist's activities and findings;
• Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed;
• Participates in oversight and monitoring reviews of the MCO including but not limited to EQR and NCQA reviews as appropriate;
• Responsible for interpreting and assisting in developing and maintaining policies and procedures.

Knowledge, Skills and Abilities:

• Considerable knowledge of the laws, regulations and policies that govern the program
• Exceptional interpersonal and communication skills
• Strong problem solving, negotiation, arbitration, and conflict resolution skills
• Excellent computer skills and proficiency in Microsoft Office products (such as Word, Excel, Outlook, and PowerPoint)
• Demonstrated ability to verify documents for accuracy and completeness; to understand and apply laws, rules and regulations to various situations; to apply regulations and policies for maintenance of consumer medical records, personnel records, and facility licensure requirements
• Ability to make prompt independent decisions based upon relevant facts
• Ability to establish rapport and maintain effective working relationships
• Ability to act with tact and diplomacy in all situations
• Ability to maintain strict confidentiality in all areas of work
• Ability to analyze and interpret policy and procedural guidelines and to resolve problems and questions, independently
• Ability to complete non-routine activities and tasks that require deviation from established procedures which includes the ability to choose the appropriate course of action and recognize the existence of and differences among situations
• Ability to use initiative and judgment in resolving problems not covered by established priorities or prior experience

Education/Experience Required:

Bachelor's Degree and two (2) years of credentialing, provider enrollment, auditing or monitoring experience in MH/SU/I-DD. Must have ability to travel. MUST reside in North Carolina.

Education/Experience Preferred:

N/A

Licensure/Certification Requirements:

N/A