Senior In-House Provider Operations Representative

Operations Miramar, Florida


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Company Overview

Clear Spring Health is a newly formed health insurance company within Delaware Life Insurance Company building a health insurance operation headquartered in Chicago, IL. Clear Spring Health’s insurance operations are conducted through multiple health insurance plans. The Clear Spring Health management team is located in Miramar, FL and provides all supporting services to the health insurance plans and Clear Spring Health Holding Company.

Job Summary

The Senior In-House Provider Operations Representative is responsible supporting Provider Relations Field Reps, maintaining working relationship with the existing provider’s networks.

Responsibilities

  • Maintains regular contact with key provider organizations and serves as a liaison to internally resolve complex issues. Develops strong interpersonal relationships and assigned providers.
  • Researches and resolves incoming escalated provider inquiries within contract guidelines. Educates providers on new protocols, policies and procedures.
  • Assist with Out of network negotiations.
  • May assist with physician recruitment by identifying specific providers within a designated territory, facilitating the distribution of provider agreements.
  • Ensure provider database and documentation is up-to-date, accurate and complete.
  • Ensure new physician contracts are entered promptly and accurately.
  • Ensure credentialing documents are submitted for process and assist CVO with follow up with providers on any missing documents.
  • Provider Directory review for accuracy.
  • Special projects as assigned or directed.

Qualifications

  • At least 2-3 years of experience in a health care and/or managed care environment, claims experience preferred
  • Excellent written and verbal communications skills
  • Informational knowledge of health plan software systems, examples, QNXT, Cactus
  • Ability to effectively manage multiple priorities
  • Excellent written and verbal communication skills
  • Ability to prepare and present formal presentations
  • Strong effective interpersonal skills
  • Ability to analyze data and track and trend variance from goals
  • Functional computer skills in Microsoft office