Provider Network Specialist

Workforce Classification:

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As a Provider Network Specialist, you will be responsible for the maintenance of all professional and institutional providers, including national network provider information within the provider source systems and other applicable systems. You will research and update provider demographic information timely and accurately for directories, provider mailings and claims payment and act as a liaison between Premera Blue Cross and its providers.

What you’ll do: 

• Ensure data integrity of provider directories for all markets including all demographic, specialty, credentialing, and both contractual and non-network participation.
• Provide timely, accurate, and concise responses to inquiries made by internal departments and providers related to networks, contract information, agreement ID’s, claims, payment methods, on-line directory, provider mailings, and national networks.
• Research and resolve provider inquiries and complex claims issues relating to provider information by investigation/review within department standards/processes.
• Assure compliance with the National Committee for Quality Assurance (NCQA), Office of the Insurance Commissioner (OIC), and other regulatory agencies/requirements.
• Process incoming provider information updates and contract implementation requests, utilizing different applications and websites (ex. vendor databases, licensing website) and complete the necessary updates into the provider source system.
• Verify provider information for In Network and Out of Network providers (including but not limited to demographic information, remittance, location address, licensure etc.), utilizing applicable resources (ex. phone, email, vendor databases etc.).
• Coordinate with internal departments, such as Care Management, Claims, Customer Service, and Systems and Reporting to answer questions and resolve provider related problems.
• Assist customer service with inquiries and unique provider issues.
• Maintain accurate and complete electronic documentation on all provider correspondence.
• Provide support for Provider Network Executives (PNEs) and provider network.
• Provide input on improvements regarding workflow, procedures, or policies, and make recommendations to management.

What you’ll bring: 

• High School Diploma or GED. (Required)
• (3) years of experience in a production or customer service environment requiring attention to detailed procedures. (Required)
• Minimum of one year of hands-on experience in healthcare administration, including provider data management responsibilities.
• Knowledge of other internal department operations or functions that assist in resolution of provider inquiries.
• Knowledge of medical and/or medical insurance terminology.
• Experience in working with Microsoft Word and Excel.

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