Cmco Jobs (NOW HIRING)

We are recruiting for a network engagement specialist in Fresno, CA.

The Network Engagement Specialist is responsible for coordinating necessary services for members with out of network providers, hospitals and groups as needed.  This role includes overseeing provider communications, issue resolutions, case submissions, and case closures, as well as managing data exchanges with care partners, local hospitals, and other in and out of network providers. By building strong connections between UPN and our provider partners, the Network Engagement Specialist will enhance collaboration and service delivery. Additionally, the Specialist will educate local hospitals, skilled nursing facilities, and other ancillary providers on UPN's processes and workflows. The Specialist will also facilitate efficient routing to in-network providers and facilities when needed. This role involves a mix of administrative tasks and project management, with a strong focus on enhancing member satisfaction and maintaining effective provider relationships. The Specialist will work closely with the Medical Director (MD), Associate Medical Director (AMD), and the Contracting & Managed Care Officer (CMCO). 

Performance Area 1: Provider Account Management 

• Work closely with in and out of network hospitals, facilities, healthcare providers, and ancillary vendors to coordinate effective care for members based on MD, AMD and utilization management guidelines. 
• Primary contact for intake of Letter of Agreements (LOAs), review of LOA and associated authorizations, and execution of the LOA. 
• Intake, review and closure of grievances by coordinating with internal and external teams, health plans and providers. 
• Reroute and coordinate referrals based on the direction provided by the MD, AMD and UM staff.  
• Assist with expedited referrals as designated by MD and AMD by coordinating internally and/or externally. 
• Submit referral modification requests as guided by MD and AMD. 
• Work with internal teams to schedule primary and specialty appointments as directed by MD and AMD. 
• Intake Peer-to-Peer requests and process according to establish protocols.
• Ongoing, professional, and effective communication with all providers in UPN's network 
• Maintain a professional relationship with all internal and external care partners.  
• Provide exceptional customer service 

Performance Area 2: Provider Education and Network Management

• Maintain accurate records of errands and vehicle usage.
• Answer UPN customer service phone line to appropriately address and/or reroute inquiries. 
• Handle administrative tasks related to provider relations, including documentation, reporting, and follow-up communications.
• Audit Health Plan provider rosters and directories to ensure UPN Network providers are listed accurately.  Work with the Management Service Organization and Health Plans to address any deficiencies. 
• Support providers through the credentialing/re-credentialing process, including addressing provider questions, ensuring timely completion of applications, and supporting UPN's credentialing team. 
• Collaborate with internal and external care partners in the creation and distribution of orientation and educational materials to all levels of personnel within a hospital, and ancillary services settings. 
• Build provider awareness and engagement with UPN for potential contract opportunities for ancillary services and hospital partnerships.  
• Other tasks as assigned. 

Performance Area 3: Cross Functional UPN Support

• Oversee incoming mail, organize and distribute to the appropriate personnel.  
• Intake of complaints and grievances from government agencies and health plan partners.
• Review, research, gather and formulate proper responses in a timely, thoughtful manner for complaints and grievances. 
• Intake of Medicare Advantage Broker requests for approved UPN information.
• Intake and documentation of Health Plan Partner & Medicare Advantage Broker complaints.
• Administrative support to CMCO and MD as needed.
• Serve as internal UPN provider advocate by communicating key provider pain points and work with key stakeholders to advance support of UPN's contracted ancillary providers. 
• Collaborate with Marketing, Sales, Provider Data, Credentialing, Operations, and other teams to coordinate cross-functional in-market activities. 
• Work closely with the MD, CMCO, and Provider Relations staff to align initiatives with organizational goals and improve care transitions.
• Ensure compliance with all relevant regulations and organizational policies related to member care and provider relations.
• Track claims that were erroneously sent to the UPN Office and re-route them to UPN's Claims team for proper processing. Contact the facility to ensure that future claims are sent to the correct address. 
• Travel short distances while using a company vehicle to pick up supplies, deliver documents, attend meeting offsite.
• Must be able to independently plan, organize, prioritize, schedule, coordinate, and make decisions related to assigned responsibilities.
• Must have a very strong customer service orientation, positive attitude, and be highly self-motivated, directed, and change oriented.

Performance Area 4: General Corporate Expectations

• Attend and actively participate in all meetings (e.g., department meetings, program meetings, employee staff meetings) and other activities as required or assigned.
• Attend workshops/seminars as necessary to increase skills and knowledge to provide effective care, treatment, and/or leadership.
• Support the overall needs of the health center by working flexible or extended hours when necessary.
• Demonstrate awareness of, and compliance with, organizational mission and objective of UHC to provide health care access and support services for all members of the community.
• Other work-related duties as assigned by supervisor. Duties and responsibilities may be added, deleted, or changed at any time at the discretion of management, formally or informally either verbally or in writing.
• Maintain confidentiality and respect for information regarding patients and other team members; abide by UHC Rules of Confidentiality and general HIPAA regulations regarding privacy.
• Display a positive, professional and respectful demeanor at all times toward employees, peers, professional contacts, and patients served, maintaining a professional appearance and positive image for the health centers.
• Contribute to the team by promoting positive staff interaction, maintains open communication with other programs/departments.

QUALIFICATION REQUIREMENTS:

EDUCATION:

• High School Diploma or GED required
• Bachelor's degree in Business, Health Care Administration, Communications or a related field is preferred; equivalent work experience and education will be considered in lieu of a degree.
• Completed training program in Medical Assisting from Accredited College is preferred.

PRIOR EXPERIENCE:

• Two (2) or more years of experience in the healthcare industry navigating relationships around providers and insurance networks is preferred.

LICENSE/CERTIFICATION:

• Possess a valid CA driver's license.

SKILLS:

• Bilingual (English/Spanish) is preferred.
• Must be able to establish rapport and effective working relationships with providers and health center administrators.
• Must have excellent communication skills including negotiation skills; must be persistent and persuasive.
• Must have advanced proficiency in various computer applications and exemplary email communications skills.
• Must be able to prioritize multiple responsibilities and manage a large workload within budget and time lines.
• Must have excellent problem-solving skills and self-motivation.
• Must have the ability to develop alternative solutions to problems.
• Must be able to prepare clear, concise, thorough, meaningful, and grammatically correct written reports, letters, memos and other documents.

The hourly wage range that UHC reasonably expects to pay for the position upon hire starts at $29.27 an hour. Our salaries are dependent on knowledge, skills, and experience.

In addition, our comprehensive benefits package for regular status employees includes:

• Medical, Dental, and Vision insurance with low premium cost
• Paid time off and paid holidays
• 401k plan with matching contribution
• Educational Assistance
• Employee discounts and more!