Provider Network Operations Representative

• Support provider network operations, including provider onboarding, terminations, demographic updates, and maintenance of provider records

• Coordinate provider-related activities across Contracting, Credentialing, Claims, Provider Relations, and other internal teams

• Serve as a primary point of contact for provider operational inquiries, network status questions, and administrative support needs

• Investigate, track, and resolve provider issues related to claims, reimbursement, EDI rejections, network participation, and operational processes

• Maintain accurate provider records, documentation, tracking logs, and operational workflows

• Assist with provider directory validation, audits, regulatory reporting, and data accuracy initiatives

• Compile and distribute operational reports related to provider network activities and performance

• Collaborate with internal departments and field-based network teams to support provider onboarding, education, and operational readiness

• Participate in process improvement initiatives designed to enhance provider experience, operational efficiency, and data quality

• Support health plan, regulatory, and organizational compliance requirements, including audit preparation and readiness activities

• Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred
• At least 2 years of experience in provider network operations, provider relations, healthcare operations, managed care, health plan administration, or a related healthcare environment
• Experience supporting provider onboarding, provider maintenance, claims resolution, credentialing, or network operations
• Strong organizational skills with exceptional attention to detail and accuracy
• Excellent customer service, communication, and relationship-building skills
• Ability to prioritize multiple tasks and meet deadlines in a fast-paced environment
• Proficiency with Microsoft Office Suite, including Word, Excel, Outlook, and Teams
• Ability to work independently while collaborating effectively across multiple departments
• Experience working with health plans, IPAs, ACOs, MSOs, or value-based care organizations preferred
• Knowledge of provider data management, provider directories, claims operations, credentialing, and contracting processes preferred
• Experience researching and resolving provider issues related to claims, reimbursement, and network participation preferred
• Familiarity with CMS, DMHC, and regulatory requirements related to provider network operations preferred
• Experience working with provider management systems, healthcare platforms, or network databases preferred

Demonstrates expertise in provider network operations, including onboarding, claims resolution, and compliance with regulatory requirements. Proficient in maintaining accurate provider records and collaborating across departments to enhance operational efficiency and provider experience.

• Provider Network Operations
• Claims Resolution
• Provider Onboarding
• Regulatory Compliance
• Provider Data Management

• Provider Relations
• Healthcare Operations
• Credentialing
• Contracting Processes
• Claims Operations
• Data Accuracy Initiatives
• Operational Workflows
• Process Improvement
• Audit Preparation
• Network Participation

• Organizational Skills
• Attention to Detail
• Customer Service
• Communication Skills
• Relationship-Building

• Healthcare Administration
• Managed Care
• Health Plan Administration
• Value-Based Care
• CMS
• DMHC

• Microsoft Office Suite
• Provider Management Systems
• Healthcare Platforms
• Network Databases