UMWA Health and Retirement Funds
Provider Network Specialist
UMWA Health and Retirement Funds, Beckley, West Virginia, us, 25802
Overview
SUMMARY : Assists in the development of provider networks, maintains provider network database and records, handles inquiries regarding the Primary Care Physician (PCP) Network, establishes and maintains databases and web applications to support, document, and manage team collaboration, assists with audits of the Funds and those conducted by the Funds, assists with special projects, and provides general administrative support for office activities. Responsibilities
Maintains database for Funds’ PCP and other cooperating provider networks. Responsible for credentialing network providers, verifying licenses and certifications; documenting and preparing credentialing data and entering it into the Funds system; contacting physician offices to request additional or missing information. Obtains network participation agreements and network enrollment information from providers. Responds to inquiries, explains network practices and resolves problems, either verbally or in writing concerning Funds’ health benefits, payments, programs, and policies. Updates and sorts network, provider and claims data. Prepares spreadsheets and reports as requested. Promotes and provides education in the use of the Funds electronic claims submission, payment programs and the Funds internet-based eligibility and claims inquiry program to providers. Serves as the Funds internet web master in all assigned areas. Responsible for coordinating incoming information and updating the Funds Internet website relating to health information updates pertinent to the Funds beneficiary and provider populations. Maintains records and data and the preparation of reports, surveys, presentations and other projects. Participates in Medicare Audit, collaborating with clinical reviewers, consultants, and healthcare providers to obtain medical records, follow up documentation, and record notes. Assists in the development of healthcare programs and special projects serving beneficiaries, providers and coal companies. Schedules, organizes and participates in meetings for Funds staff, beneficiaries, providers, contractors and other parties. Processes incoming and outgoing mail, as requested. Covers the office reception desk on a rotation, as needed basis. Maintains office supplies and inventory. Routes invoices for payment from maintenance and vendor related office items. Provides support to beneficiaries with health benefits claims and/or billing problems. Answers basic eligibility and benefits questions, and provides general information concerning Funds' benefits, regulations, and programs. Communicates, verbally and in writing, with suppliers, health care providers, beneficiaries, and Funds' personnel on a variety of matters including network maintenance, covered benefits, coordination of benefits, and hold harmless. Maintains confidentiality of provider, coal company, and beneficiary records. Responsible for adhering to all Funds policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information. Travels as required to conduct Funds’ business. Performs other administrative duties as assigned. Assists with day-to-day activities of the office. Qualifications
Education and/or Experience High school diploma or General Education Degree (GED) PLUS 3 years in a position utilizing word processing and data management skills including an automated data base such as SharePoint, PLUS two years of prior experience working with people to provide assistance and solve problems, receiving and routing visitors, answering high volume of telephone calls, general administrative duties, and interpreting basic regulations and policies and procedures. Technical, Business, and Industry Knowledge Must pass speeded typing test at minimum of 45 wpm with 5 or fewer errors. Demonstrated ability to operate office equipment including PC/ data terminals, scanners, copier machines, postage machines, and microfilm/microfiche reader/reader-printers. Basic proficiency in computer applications such as Microsoft Office and SharePoint with demonstrated ability to enter, edit, print and protect data in a worksheet or data program and use formulas to perform basic calculations such as sorting, adding, subtracting, dividing and multiplying; ability to display information. Communication Skills Intermediate - Ability to speak effectively before groups such as Funds' employees, beneficiaries, or third-party administrator for purposes such as gathering information, providing advice or counsel or making recommendations regarding procedures or policies. Intermediate - Ability to read and interpret documents such as operating instructions, procedures and processing manuals. Ability to write reports, business correspondence, and procedure manuals. Mathematical Skills Basic - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Certificates, Licenses, Registrations None Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, and ability to adjust focus. Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Probationary Period
90 standard workdays pursuant to Sections 5.06, 5.07 and 5.08 of the Collectively Bargained Agreement. Complete Background Check Required
Complete background check required.
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SUMMARY : Assists in the development of provider networks, maintains provider network database and records, handles inquiries regarding the Primary Care Physician (PCP) Network, establishes and maintains databases and web applications to support, document, and manage team collaboration, assists with audits of the Funds and those conducted by the Funds, assists with special projects, and provides general administrative support for office activities. Responsibilities
Maintains database for Funds’ PCP and other cooperating provider networks. Responsible for credentialing network providers, verifying licenses and certifications; documenting and preparing credentialing data and entering it into the Funds system; contacting physician offices to request additional or missing information. Obtains network participation agreements and network enrollment information from providers. Responds to inquiries, explains network practices and resolves problems, either verbally or in writing concerning Funds’ health benefits, payments, programs, and policies. Updates and sorts network, provider and claims data. Prepares spreadsheets and reports as requested. Promotes and provides education in the use of the Funds electronic claims submission, payment programs and the Funds internet-based eligibility and claims inquiry program to providers. Serves as the Funds internet web master in all assigned areas. Responsible for coordinating incoming information and updating the Funds Internet website relating to health information updates pertinent to the Funds beneficiary and provider populations. Maintains records and data and the preparation of reports, surveys, presentations and other projects. Participates in Medicare Audit, collaborating with clinical reviewers, consultants, and healthcare providers to obtain medical records, follow up documentation, and record notes. Assists in the development of healthcare programs and special projects serving beneficiaries, providers and coal companies. Schedules, organizes and participates in meetings for Funds staff, beneficiaries, providers, contractors and other parties. Processes incoming and outgoing mail, as requested. Covers the office reception desk on a rotation, as needed basis. Maintains office supplies and inventory. Routes invoices for payment from maintenance and vendor related office items. Provides support to beneficiaries with health benefits claims and/or billing problems. Answers basic eligibility and benefits questions, and provides general information concerning Funds' benefits, regulations, and programs. Communicates, verbally and in writing, with suppliers, health care providers, beneficiaries, and Funds' personnel on a variety of matters including network maintenance, covered benefits, coordination of benefits, and hold harmless. Maintains confidentiality of provider, coal company, and beneficiary records. Responsible for adhering to all Funds policies and procedures adopted to comply with the Health Insurance Portability and Accountability Act (HIPAA) governing the privacy, security, and use of protected health information. Travels as required to conduct Funds’ business. Performs other administrative duties as assigned. Assists with day-to-day activities of the office. Qualifications
Education and/or Experience High school diploma or General Education Degree (GED) PLUS 3 years in a position utilizing word processing and data management skills including an automated data base such as SharePoint, PLUS two years of prior experience working with people to provide assistance and solve problems, receiving and routing visitors, answering high volume of telephone calls, general administrative duties, and interpreting basic regulations and policies and procedures. Technical, Business, and Industry Knowledge Must pass speeded typing test at minimum of 45 wpm with 5 or fewer errors. Demonstrated ability to operate office equipment including PC/ data terminals, scanners, copier machines, postage machines, and microfilm/microfiche reader/reader-printers. Basic proficiency in computer applications such as Microsoft Office and SharePoint with demonstrated ability to enter, edit, print and protect data in a worksheet or data program and use formulas to perform basic calculations such as sorting, adding, subtracting, dividing and multiplying; ability to display information. Communication Skills Intermediate - Ability to speak effectively before groups such as Funds' employees, beneficiaries, or third-party administrator for purposes such as gathering information, providing advice or counsel or making recommendations regarding procedures or policies. Intermediate - Ability to read and interpret documents such as operating instructions, procedures and processing manuals. Ability to write reports, business correspondence, and procedure manuals. Mathematical Skills Basic - Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs. Certificates, Licenses, Registrations None Physical Demands
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms; and talk or hear. The employee frequently is required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, and ability to adjust focus. Work Environment
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Probationary Period
90 standard workdays pursuant to Sections 5.06, 5.07 and 5.08 of the Collectively Bargained Agreement. Complete Background Check Required
Complete background check required.
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