In-House Provider Operations Representative
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.
Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina and offers Medicare Prescription Drug Plans in 42 states plus DC.
Group 1001, and its affiliated companies, is strongly committed to providing a supportive work environment where employee differences are valued. Diversity is an essential ingredient in making Group 1001 a welcoming place to work and is fundamental in building a high-performance team. Diversity embodies all the differences that make us unique individuals. All employees share the responsibility for maintaining a workplace culture of dignity, respect, understanding and appreciation of individual and group differences.
This role is responsible supporting Provider Relations Field Reps, maintaining working relationship with the existing provider’s networks.
- 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.
- 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