Provider Network Specialist

Provider Network Specialist

Edera L3C is a fast-growing healthcare consultancy that addresses today's issues and helps create tomorrow's solutions by connecting the brightest minds in healthcare. Our team of management, technology, and creative services consultants work collaboratively with industry experts who bring deep experience and expertise to create transformational business solutions. We believe complex challenges and multi-faceted opportunities call for multi-disciplinary approaches and that's how we work. We transform healthcare by bringing industry best practices from the private sector to the public sector, and the public sector to the private sector. Edera is an L3C (a variation of a limited liability company) that places "purpose before profit;" a social enterprise venture. This means we are focused on a socially beneficial mission to transform organizations rather than being driven to maximize income. Profits beyond our business sustainability goals are reinvested into communities or clients.

Position Description

The Provider Network Specialist is responsible for developing, maintaining, and optimizing a robust healthcare provider network. This role ensures network adequacy, compliance with regulatory standards, and cost-effective contracting strategies. The position involves provider recruitment, contract negotiation, credentialing oversight, and relationship management to deliver high-quality care to members.

Type of Employment: Full-Time salaried and fully benefited position

Work Location/Travel: Remote. Up to 25% travel required; applicants must be free from travel restrictions to accommodate evolving needs of the client.

Salary Range: $83,210 - 96,345 base salary, depending on experience and location. Competitive salary/pay, potential for bonuses. There are multiple factors that are considered in determining final pay for a position, including, but not limited to, relevant work experience, skills, certifications and competencies that align to the specified role, geographic location, education and certifications as well as contract provisions regarding labor categories that are specific to the position. The pay range for this position is highly competitive but dependent upon employment type (1099, contract, W2).

Role Reports to:Hiring Manager

Direct Reports: This role has no direct reports

Responsibilities:

• Network Development & Maintenance
• Identify, recruit, and contract with healthcare providers (physicians, specialists, hospitals, behavioral health, ancillary services) to ensure comprehensive network coverage.
• Analyze network adequacy and identify gaps; implement strategies to address deficiencies.
• Maintain accurate provider data in internal systems and ensure compliance with data quality standards.
• Contracting & Negotiation
• Negotiate provider agreements focusing on quality care and cost-effectiveness.
• Review and analyze reimbursement data to support rate-setting strategies.
• Ensure all contracts meet organizational and regulatory requirements.
• Credentialing & Compliance
• Oversee provider credentialing and re-credentialing processes in collaboration with credentialing teams.
• Ensure adherence to state, federal, and organizational compliance standards, including HIPAA.
• Provider Relations
• Serve as the primary liaison between providers and internal departments.
• Conduct provider orientations and ongoing educational outreach on policies, billing, and operational procedures.
• Resolve provider inquiries related to claims, authorizations, and operational issues.
• Data Analysis & Reporting
• Monitor provider performance using quantitative and qualitative metrics.
• Prepare reports on network adequacy, provider performance, and contracting outcomes. Utilize data to recommend process improvements and efficiency enhancements.

Knowledge Requirements

• Healthcare Industry Fundamentals
• Understanding of managed care principles, provider contracting, and reimbursement methodologies (e.g., fee-for-service, capitation, value-based care).
• Regulatory Compliance
• Knowledge of state and federal regulations (Medicare, Medicaid, ACA, HIPAA).
• Provider Network Standards
• Familiarity with network adequacy requirements and credentialing standards.
• Claims and Billing Processes
• Basic understanding of claims adjudication, prior authorization, and utilization management.
• Data Analysis
• Ability to interpret provider performance metrics, cost data, and network adequacy reports.
• Quality Programs
• Awareness of HEDIS, NCQA, and other quality improvement initiatives.

Skills Requirements

• Negotiation & Contracting
• Strong negotiation skills for provider agreements and reimbursement rates.
• Analytical Skills
• Proficiency in analyzing data to identify network gaps and cost-saving opportunities.
• Communication
• Excellent verbal and written communication for provider relations and internal collaboration.
• Problem-Solving
• Ability to resolve provider issues related to claims, credentialing, and operational processes.
• Technical Skills
• Competence in provider data management systems, Microsoft Excel, and reporting tools.
• Relationship Management
• Building and maintaining positive relationships with providers and internal stakeholders.
• Project Management
• Organizational skills to manage multiple contracts, deadlines, and compliance tasks

Education/Certification Required:

• Bachelor's degree in Healthcare Administration, Business Administration, or related field
• One or more certifications from the "certifications preferred" section below

Certifications Preferred

• Certified Professional in Healthcare Quality (CPHQ) - demonstrates expertise in healthcare quality and performance improvement.
• Certified Provider Credentialing Specialist (CPCS) - for those involved in credentialing and provider data management.
• Managed Care Professional (MCP) - focuses on managed care principles and practices.
• Certified Medical Manager (CMM) - for advanced healthcare management knowledge.
• VA and/or DoD experience preferred but not required.

Experience Required:

• 3-5 years of experience in Provider network management
• Contract negotiation and reimbursement methodologies
• Managed care operations (Medicaid, Medicare, or Commercial plans)
• Credentialing and compliance processes

• Preferred:
  • 5+ years in a healthcare payer or managed care organization with increasing responsibility.
  • VA and/or DoD experience preferred but not required.
  • Experience with:
  • Network adequacy analysis
  • Provider relations and issue resolution
  • Data analytics and reporting tools

Technical Skills Required:

• Experience with scheduling templates, and registration protocols.
• Experience with Microsoft Dynamics preferred but not required.
• Proficiency in Microsoft Office Suite and other collaboration tools.

All applicants must be US citizens and able to obtain a Public Trust clearance. Edera participates in the E-Verify program. Edera is a drug-free workplace.

Edera is an Equal Opportunity and Affirmative Action Employer. Edera prohibits discrimination against individuals based on their race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or any other category protected by law.