Provider Network Specialist - 255100

Provider Relationship Management & Territory Engagement: Serve as the dedicated primary point of contact for contracted and prospective healthcare providers, clinic administrators, and executive office staff. Manage an assigned geographic territory, driving provider engagement initiatives, strategic network partnerships, and community outreach. Schedule and conduct regular on-site visits to provider offices, clinics, and health centers to assess operational needs, review contract performance, and foster strong partnerships. Facilitate new provider orientations and deliver ongoing training on plan policies, operational procedures, directory integrity, and contractual obligations. Maintain comprehensive and up-to-date provider records, directory data, and key contact directories across clinical, administrative, and billing departments.

Network Development, Onboarding & Credentialing: Actively prospect, engage, and recruit target providers and health systems to support network expansion goals. Guide prospective providers seamlessly through the initial application, credentialing, contract execution, and operational onboarding processes. Perform prospective provider site reviews and accessibility assessments in accordance with health plan standards and regulatory requirements. Collaborate with marketing, business development, and outreach teams to identify network gaps, support membership growth, and enhance brand presence.

Issue Resolution & Operational Support: Investigate, track, and resolve provider inquiries regarding participation status, credentialing timelines, fee schedules, claims processing, payment configuration, and member eligibility. Monitor, document, and manage escalated provider inquiries from intake through resolution in alignment with organizational standards and service-level agreements. Partner cross-functionally with Internal Claims, Contracting, Credentialing, Operations, and Medical Management teams to address complex issues and identify recurring operational trends.

Network Analytics, Quality & Compliance: Prepare and analyze reports evaluating network adequacy, geographic access, appointment availability standards, and utilization metrics. Collaborate with Quality Improvement and Population Health teams to promote clinical quality measures (including HEDIS initiatives), improve provider performance, and enhance patient care outcomes. Ensure ongoing network compliance with all federal, state, and managed care regulatory standards. Support departmental special projects and continuous improvement initiatives as assigned. Required Qualifications & Experience

Education: Associate degree required; Bachelor’s degree preferred (or equivalent relevant professional experience).

Experience: 3–5 years of direct experience in health insurance, managed care, provider relations, provider contracting, network development, or provider credentialing. In lieu of a completed degree: Minimum of 5–8 years of relevant healthcare payor/provider relations experience. Payor-Side Background: Demonstrated experience working directly with healthcare providers from the health plan/payor or managed care side. Technical Proficiency: Strong computer skills, including proficiency in Microsoft Office (Word, Excel, PowerPoint, Access) and CRM systems (Salesforce preferred).Industry Knowledge: Solid grasp of managed care principles, medical terminology, claims workflows, and healthcare reimbursement mechanisms. Mobility & Licensing: Valid driver’s license and access to a reliable personal vehicle for territory travel and provider site visits. Physical Capability: Ability to lift and carry up to 20 pounds of meeting/orientation materials as needed. Schedule Monday – Friday, 9:00 AM – 5:00 PM (35-hour work week)

Work Model: HybridFirst 4–5 Months (Onboarding & Training):Monday & Friday: Remote