Provider Services Specialist

Provider Services Specialist

The Provider Services Specialist is responsible for overseeing aspects of the provider credentialing and recredentialing process for Signature Advantage (SA) health plan. This role will ensure that providers are credentialed and configured efficiently, accurately, and in compliance with CMS (Centers for Medicare & Medicaid Services) regulations. The ideal candidate will have a strong background in Medicare Advantage operations, customer service, and regulatory compliance.

Responsibilities

• Complete the credentialing and recredentialing of all providers within the network.
• Ensure compliance with CMS regulations related to Medicare Advantage plan credentialing and recredentialing.
• Maintain accurate provider records and ensure timely updates in internal systems and external reporting.
• Work closely with internal departments (claims, utilization management, business development, network development, compliance, and finance) to ensure seamless coordination of provider credentialing and configuration.
• Address and resolve provider discrepancies, reconciliation issues, and other provider-related concerns.
• Develop and implement strategies to improve provider database.
• Load and maintain provider demographic data within internal systems.
• Ensure timely turnaround time and quality standards of provider records.
• Ensure provider information is correctly configured to support claims processing, reporting and directory services.
• Participate in audit of provider records to ensure accuracy and quality.
• Ensure prompt and accurate responses to provider inquiries.
• Resolve escalated provider complaints, grievances, disputes and appeals in collaboration with other departments.
• Ensure call center or member support staff maintain high standards of professionalism and accuracy.
• Stay updated on regulatory changes and implement necessary updates to processes and policies.
• Participate in audits related to provider services.
• Maintain thorough documentation of provider credentialing and recredentialing activities and regulatory reporting as required.
• Work closely with internal departments, including Compliance, IT, and Finance to improve provider credentialing process.
• Identify and implement process improvements to enhance efficiency, accuracy, and provider experience.
• Assist in evaluating and implementing technology solutions for provider management.
• Participate in cross-training initiatives to support other provider functional areas to ensure continuity of operations and enhancing team versatility.

Qualifications

• Bachelor's degree in business administration, Healthcare Management, or a related field (or equivalent experience).
• 2+ years of experience in Medicare Advantage credentialing, configuration, provider relations, or customer service.
• Strong knowledge of CMS guidelines for Medicare Advantage health plans.
• Experience with credentialing systems and data reconciliation.
• Excellent problem-solving, communication, and organizational skills.
• Ability to work independently and collaboratively in a small fast-paced environment.
• Proficiency in Microsoft Office Suite (Excel, Word, Outlook).
• Experience with Medicare Advantage plan operations.
• Knowledge of HIPAA regulations and health plan compliance requirements.
• Familiarity with claims processing systems.
• Travel 0-25%

About Our Line of Business

Signature Advantage, an affiliate of BrightSpring Health Services, is a Medicare Advantage Plan covering all the benefits of Original Medicare (Parts A and B) with prescription drug coverage (Part D). The Signature Advantage Plan is a unique plan allowing members to enroll year-round. The plan focuses on members who meet residential requirements in Signature Advantage participating nursing facilities. An interdisciplinary team of clinicians and innovative services allow us to meet each member's clinical needs and provide preventive, coordinated, and quality healthcare. With a dedicated nurse practitioner leading a personalized care plan, we strive to improve the health of the communities in which we serve. For more information, please visit www.signatureadvantageplan.com.

Salary Range

USD $50,000.00 - $60,000.00 / Year