Provider Network Specialist jobs in Pennsylvania
Provider Network Specialist coordinates and evaluates the contracts of a healthcare provider network. Participates in the negotiation of contracts and prepares reports and analysis of contract details and statistics. Being a Provider Network Specialist distributes contract information, status updates, and other information within the organization. Requires a bachelor's degree. Additionally, Provider Network Specialist typically reports to a manager or head of a unit/department. The Provider Network Specialist gains exposure to some of the complex tasks within the job function. Occasionally directed in several aspects of the work. To be a Provider Network Specialist typically requires 2 to 4 years of related experience. (Copyright 2024 Salary.com)
Recently Added Provider Network Specialist jobs
Network Prior Authorization & Referral Specialist
- St. Luke's University Health Network
-
Allentown, PA
PART_TIME
-
St. Luke's is proud of the skills, experience and compassion of its employees. The employees of St. Luke's are our most valuable asset! Individually and together, our employees are dedicated to satisfying the mission of our organization which is an unwavering commitment to excellence as we care for the sick and injured; educate physicians, nurses and other health care providers; and improve access to care in the communities we serve, regardless of a patient's ability to pay for health care.The Network Prior Authorization and Referral Specialist is responsible for the coordination of prior-authorizations and referral process for patients being referred for specialty care, diagnostic procedures, and surgery. Performs scheduling, insurance verification, obtaining pre-authorizations, and referrals. Ensures notification of reimbursement to physicians, nurses, financial clearance staff, and patients prior to services being rendered.JOB DUTIES AND RESPONSIBILITIES:
- Obtains prior-authorizations and referrals from insurance companies prior to procedure or testing utilizing online websites or via telephone
- Monitors and updates current Orders and Tasks; managing Orders through Allscripts and Epic to provide up to date and accurate information
- Provides insurance company with clinical information necessary to secure prior-authorization or referral
- Works in alignment with Central Scheduling and Pre Encounter Departments.
- Obtains necessary electronic referrals needed from scheduled specialty appointments
- Obtains and/or reviews patient insurance information and eligibility verification to obtain prior-authorizations for diagnostic testing, medications, injections, DME, and surgeries.
- Request retro-authorizations when needed.
- Communicates with patient regarding the visit and prior-authorization process.
- Provides support to physician group and community practices with utilization issues.
- Works with community practices to obtain prior-authorizations.
- Communicates with practices when prior-authorization is unable to be obtained and requires peer-to-peer and/or different study.
- Documents in all systems prior-authorizations to ensure proper reimbursement
- Verifies and completes patient eligibility, coverage verification, and benefit investigation for the procedure using an online application or by telephone. If the patient is not eligible on date of service or procedure is not covered, this information is relayed to the physician and the patient
- Responds to written and telephone inquiries from patients, insurance carriers and facilities regarding planned services.
- Takes an active role in facilitation team approach to functions within the department:
- Attends departmental meetings
- Actively participates as a team member in resolution of problems as they are identified
- Analyzes current procedures, bringing suggestions for improvement to the attention
- Contacts Central Scheduling, Patient Access Department, and patient, to relay precertification information
- Notify ordering physician of any prior auth denials and peer to peers to be scheduled
- Review and validate the accuracy of therapy plan/treatment plans ordered by reviewing H&P and medical records to ensure medication ordered is the same as what is being prior authorized
- Validate medication ordered is on the payer preferred drug list
- Identify buy and bill authorizations vs. delivery and document account accordingly
- Review and follow up on authorization denials and claim denials
PHYSICAL AND SENSORY REQUIREMENTS:Sitting for up to 8 hours per day, 3 hours at a time. Consistent use of hands and fingers for typing, telephones, data entry, etc. Occasional twisting and turning. Uses upper extremities to lift and carry up to 15 pounds. Stoops, bends, and reaches above shoulder level to retrieve files. Hearing as it relates to normal conversation. Seeing as it relates to general vision. Visual monotony when reading reports and reviewing computer screen.EDUCATION:High School diploma or equivalent required.TRAINING AND EXPERIENCE:One to two years of experience in medical billing office, medical setting or insurance company. Working knowledge of medical business office procedures and basic accounting and detailed understanding of ICD-10 and CPT codes. Strong knowledge of regulatory standards and compliance requirements. Previous pre-certification experience helpful. Previous Medical Assistant experience highly desirable.Please complete your application using your full legal name and current home address. Be sure to include employment history for the past seven (7) years, including your present employer. Additionally, you are encouraged to upload a current resume, including all work history, education, and/or certifications and licenses, if applicable. It is highly recommended that you create a profile at the conclusion of submitting your first application. Thank you for your interest in St. Luke's!!St. Luke's University Health Network is anEqual Opportunity Employer. -
- 18 Days Ago
Advanced Practice Provider, Cardiology
- Allegheny Health Network
-
Erie, PA
FULL_TIME
- Company : Allegheny Health Network Job Description : GENERAL OVERVIEW: The Advanced Practice Providers at Allegheny Health Network are an integral part of the care delivery system working together to ...
- 17 Days Ago
Advanced Practice Provider, Neurology
- Allegheny Health Network
-
Pittsburgh, PA
FULL_TIME
- Company : Allegheny Health Network Job Description : GENERAL OVERVIEW: The Advanced Practice Providers at Allegheny Health Network are an integral part of the care delivery system working together to ...
- 2 Months Ago
VP Reimbursement, Provider & Network Programs
- Highmark Health
-
Pittsburgh, PA
FULL_TIME
- Company : Highmark Health Job Description : JOB SUMMARY This role is accountable for any program or strategic tactic to drive provider performance in the domains of reimbursement and network programs....
- 1 Month Ago
Provider Network Development and Contracting Representative
- FourStone Partners
-
West Chester, PA
FULL_TIME
- FourStone Partners is an innovative consulting firm specializing in business development, sales outsourcing, and operational support services within the Workers' Compensation industry. FourStone Partn...
- 21 Days Ago
Provider specialist
- Zolon Tech Solutions, Inc.
-
Philadelphia, PA
FULL_TIME
- Location : Philadelphia, PA Duration : 04 Months Job Description : Remote Remote The Contract Specialist ensures contract data and documents are represented correctly in all plan operating systems, fu...
- 4 Days Ago
Provider Network Specialist jobs at Popular Companies
Network Technician/Network Engineer/Network Support Engineer(NO C2C CANDIDATES considered)
- Sharp Decisions
-
Graham, NC
- Title : Network Technician/Network Engineer/Network Support Engineer(NO C2C CANDIDATES considered) Contract duration : 1...
- 6/10/2024 12:00:00 AM
Sr. Specialist Network Engineer
- IT
-
Phoenix, AZ
- Nestlé Information Technology is the digital arm of the world’s largest nutrition, health, and wellness company. With 15...
- 6/8/2024 12:00:00 AM
Network Engineer
- Govcio LLC
-
Martinsburg, WV
- Overview: GovCIO is looking for a Network/Systems Engineer onsite in Martinsburg, WV (hybrid schedule). Responsibilities...
- 6/8/2024 12:00:00 AM
Network Engineer
- Leidos
-
Norfolk, VA
- Description Leidos is a FORTUNE 500 company bringing a mix of innovative technology and sector expertise to customers in...
- 6/7/2024 12:00:00 AM
Network Engineer
- Leidos
-
Arlington, VA
- Description At Leidos, we deliver innovative solutions through the efforts of our diverse and talented people who are de...
- 6/6/2024 12:00:00 AM
Network Engineer
- Leidos
-
North Charleston, SC
- Description Leidos is actively hiring for an experienced Network Engineer to join our team in North Charleston, SC. This...
- 5/31/2024 12:00:00 AM
Network Engineer
- Primient
-
Decatur, IL
- Network Engineer Decatur, IL Ready for a IT career with more impact ? Join a market leader in ingredient manufacturing t...
- 5/23/2024 12:00:00 AM
Network Engineer
- Leidos
-
Undisclosed, MD
- Description Provides assistance in all aspects of network management from network design through implementation, mainten...
- 4/19/2024 12:00:00 AM
About Pennsylvania
Pennsylvania (/ˌpɛnsɪlˈveɪniə/ (listen) PEN-sil-VAY-nee-ə), officially the Commonwealth of Pennsylvania, is a state located in the northeastern and Mid-Atlantic regions of the United States. The Appalachian Mountains run through its middle. The Commonwealth is bordered by Delaware to the southeast, Maryland to the south, West Virginia to the southwest, Ohio to the west, Lake Erie and the Canadian province of Ontario to the northwest, New York to the north, and New Jersey to the east.
Pennsylvania is the 33rd-largest state by area, and the 6th-most populous state according to the most recent of...
Source: Wikipedia (as of 04/11/2019). Read more from Wikipedia
Income Estimation for Provider Network Specialist jobs
$58,614 to $87,633
Most Popular Cities in Pennsylvania for Provider Network Specialist Jobs
What does a Provider Network Specialist do?
Provider Network Specialist in Anderson, IN
Creates, maintains, and ensures the integrity of the provider data in DHP’s multiple claims payments systems and provider interface programs.
January 07, 2020
Provider Network Specialist in Tucson, AZ
Identifies and works with the provider to address education needs relative to DHP’s new product lines/expansions, utilization management, claims submission, and back-end issues resolution requirements of each assigned provider’s contract.
January 12, 2020
The Provider Network Specialist will work closely with all facets of the business, primarily with Care Management, Claims and Business Development.
January 08, 2020
Provider Network Specialist in Oakland, CA
Build and maintain a successful working relationship with Integra Managed Care and network providers.
December 03, 2019