Provider Network Specialist-Disputes (Remote Option-NC)

Competitive Compensation & Benefits Package! Position eligible for – Annual incentive bonus planMedical, dental, and vision insurance with low deductible/low cost health planGenerous vacation and sick time accrual12 paid holidaysState Retirement (pension plan)401(k) Plan with employer matchCompany paid life and disability insuranceWellness ProgramsPublic Service Loan Forgiveness Qualifying EmployerSee attachment for additional details. Location: Remote option; Available for any of Partners' NC locationsProjected Hiring Range: Depending on Experience Closing Date: Open Until FilledPrimary Purpose of Position: This position manages provider disputes, sanctions, and terminations and monitors the process for each of those ensuring a high-quality network to serve Partners members. Role and Responsibilities: A Provider Network Specialist’s primary duties may be one or more of the following:Oversees the follow-up and management of the provider dispute resolution process including notification letters of receipt of dispute, tracks timelines, maintains dispute log, conducts complete and thorough investigation of dispute, composes notification letter to provider related to that decision.Visits provider agencies to facilitate communication & collaboration as needed;Obtains and maintains information regarding provider sanctions, terminations and disputes;Completes routine and ongoing contract compliance monitoring to ensure that services are consistent with funding requirements, best practices, provider contracts and federal/state rules and regulations;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 through the Network Management Committee;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 subject matter expert and as a resource to other departments within the LME/MCO on provider issues specifically related to provider terminations, sanctions and dispute information when appropriate;Manages notification and tracking of provider contract terminations; Participates in Provider Forums as requested and provides technical support and assistance to Provider Councils as needed;Monitors all NMC issued sanctions for all providers;Maintains a log of all Medicaid and IPRS procurement contract terminations;Participates in oversight and monitoring reviews of the MCO including but not limited to NCQA and EQR reviews as appropriate.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 programExceptional interpersonal and communication skillsStrong problem solving, negotiation, arbitration, and conflict resolution skillsExcellent 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 requirementsAbility to make prompt independent decisions based upon relevant factsAbility to establish rapport and maintain effective working relationshipsAbility to act with tact and diplomacy in all situationsAbility to maintain strict confidentiality in all areas of work Education/Experience Required: Bachelor’s Degree in mental health, public health, social work, psychology, education, sociology, business or public administration and two (2) years of experience in a community, business, or governmental program in health-related fields, social work or education including experience in network operations, provider relations and management experience. Education/Experience Preferred: Master’s Degree with clinical licensure preferred.Licensure/Certification Requirements: