About this role
About the Role
The Provider Network Operations Representative supports the day-to-day operational functions of the provider network in the OC-IE-SD markets and may assist with designated non-CA and MSO Client accounts. This role serves as a key operational liaison between providers, internal departments, and network leadership to ensure accurate network data, efficient workflows, and timely issue resolution. Reporting to the VP, Network Management , this role is execution-focused and plays a critical role in maintaining provider network integrity, supporting onboarding and maintenance activities, and ensuring compliance with health plan and regulatory requirements.
- Provider Network Operations & Support Facilitate compliance-related activities to meet health plan, DMHC, DHCS, and regulatory requirements.
- Support provider network operations including onboarding, terminations, issue resolutions, communications, credentialing, provider updates, and maintenance of department files.
- Coordinate provider-related operational activities across internal teams such as Contracting, Credentialing, Claims, and Network Management.
- Assist Network Management provider engagement functions as needed.
- Provider Communication & Issue Resolution Intake and solution provider inquiries adhering to administrative processes.
- Track, research, and resolve operational issues timely and professionally.
- Escalate complex or systemic issues to leadership as appropriate.
- Data Accuracy & Reporting Maintain accurate documentation of provider records, interactions, and workflows.
- Assist with audits, directory validation, and regulatory reporting requirements.
- Support preparation of reports related to provider network operations and performance.
- Cross-Functional Collaboration Partner with Provider Network, Credentialing, Contracting, Claims, and Quality teams to support seamless network operations.
- Participate in meetings and initiatives related to network optimization and operational improvements.
- Support market-specific network initiatives as assigned.
- Coordinate with the Quality and Risk team to distribute reports and collect data from providers.
- Compliance & Process Adherence Ensure compliance with health plan requirements, company policies, and state and federal regulations (e.g., DMHC, CMS).
- Follow established workflows and contribute to process improvements that enhance efficiency and accuracy.
- Support readiness for internal and external audits.
- Other duties as assigned.